CLINICAL PRACTICE GUIDELINES
A Core Set of Outcome Measures for
Adults With Neurologic Conditions
Undergoing Rehabilitation
A CLINICAL PRACTICE GUIDELINE
Jennifer L. Moore, PT, DHS, NCS,
Kirsten Potter, PT, DPT, MS,
Kathleen Blankshain, PT, DPT,
Sandra L. Kaplan, PT, DPT, PhD,
Linda C. O’Dwyer, MA, MSLIS, and
Jane E. Sullivan, PT, DHS, MS
South Eastern Norway Regional
Knowledge Translation Center, Sun-
naas Rehabilitation Hospital, Oslo,
Norway, and Institute for Knowl-
edge Translation, Carmel, Indiana
(J.L.M); Department of Physical
Therapy Education, Rockhurst Uni-
versity, Kansas City, Missouri (K.P.);
Department of Physical Therapy and
Human Movement Sciences (K.B,
J.E.S) and Galter Health Sciences Li-
brary and Learning Center (L.C.O),
Feinberg School of Medicine, North-
western University, Chicago, Illinois;
and Department of Rehabilitation
and Movement Sciences, Rutgers
School of Health Professions, New-
ark, New Jersey (S.L.K).
DOI: 10.1097/NPT.0000000000000229
174 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 174
ABSTRACT
Background: Use of outcome measures (OMs) in adult neurologic
physical therapy is essential for monitoring changes in a patient’s status
over time, quantifying observations and patient-reported function, en-
hancing communication, and increasing the efficiency of patient care.
OMs also provide a mechanism to compare patient and organizational
outcomes, examine intervention effectiveness, and generate new knowl-
edge. This clinical practice guideline (CPG) examined the literature
related to OMs of balance, gait, transfers, and patient-stated goals to
identify a core set of OMs for use across adults with neurologic condi-
tions and practice settings.
Methods: To determine the scope of this CPG, surveys were conducted
to assess the needs and priorities of consumers and physical therapists.
OMs were identified through recommendations of the Academy of
Neurologic Physical Therapy’s Evidence Database to Guide Effective-
ness task forces. A systematic review of the literature on the OMs was
conducted and additional OMs were identified; the literature search
was repeated on these measures. Articles meeting the inclusion criteria
were critically appraised by 2 reviewers using a modified version of the
COnsensus-based Standards for the selection of health Measurement
INstruments. (COSMIN) checklist. Methodological quality and the
strength of statistical results were determined. To be recommended for
the core set, the OMs needed to demonstrate excellent psychometric
properties in high-quality studies across neurologic conditions.
Results/Discussion: Based on survey results, the CPG focuses on OMs
that have acceptable clinical utility and can be used to assess change
over time in a patient’s balance, gait, transfers, and patient-stated goals.
Strong, level I evidence supports the use of the Berg Balance Scale to
assess changes in static and dynamic sitting and standing balance and
the Activities-specific Balance Confidence Scale to assess changes in
balance confidence. Strong to moderate evidence supports the use of
the Functional Gait Assessment to assess changes in dynamic balance
while walking, the 10 meter Walk Test to assess changes in gait speed,
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

REVIEWERS:
Elizabeth Anderl, PT, DPT;
Mary Beveridge;
Maggie Bland, PT, DPT, NCS, MSCI;
Rebecca Craik, PT, PhD, FAPTA;
Beth Crowner, PT, DPT, MPPA, NCS;
Linda Csiza, PT, DSc, NCS;
Vanina Dal Bello-Haas, PT, PhD;
Megan Eikenberry, PT, DPT, NCS;
Edelle Field-Fote, PT, PhD, FAPTA;
George Fulk, PT, PhD;
Timothy Hanke, PT, PhD;
Carey Holleran, PT, MPT, DHS, NCS;
Catherine Lang, PT, PhD;
Arlene McCarthy, PT, DPT, MS, NCS;
Genevieve Olivier, PT, DPT, NCS;
Miriam Rafferty, PT, DPT, PhD, NCS;
Teresa Rice, PT, MPH, NCS;
Regi Robnett, OTR/L, PhD;
Wendy Romney PT, DPT, NCS;
Amelia Siles, PT, DPT, NCS;
Irene Ward, PT, DPT, NCS;
Vanessa Warner, PT, DPT, NCS;
Kelly Westlake, PT, PhD; and
Hallie Zelenik, PT, DPT.
and the 6-Minute Walk Test to assess changes in walking distance. Best
practice evidence supports the use of the 5 Times Sit-to-Stand to assess
sit to standing transfers. Evidence was insufficient to support use of a
specific OM to assess patient-stated goals across adult neurologic condi-
tions. Physical therapists should discuss the OM results with patients and
collaboratively decide how the results should inform the plan of care.
Disclaimer: The recommendations included in this CPG are intended
as a guide for clinicians, patients, educators, and researchers to improve
rehabilitation care and its impact on adults with neurologic conditions.
The contents of this CPG were developed with support from the APTA
and the Academy of Neurologic Physical Therapy (ANPT). The Guide-
line Development Group (GDG) used a rigorous review process and
was able to freely express its findings and recommendations without
influence from the APTA or the ANPT. The authors declare no compet-
ing interest.
Video Abstract available for more insights from the authors (see Vid-
eo, Supplemental Digital Content 1, available at: http://links.lww.com/
JNPT/A214).
Key words: gait disorders, human movement system, nervous system
diseases, neurodegenerative diseases, neurologic, neurologic examina-
tion, neurologic rehabilitation, outcome and process assessment (health
care), outcome assessment (health care), patient care planning, patient
outcome assessment, postural balance, practice guideline, psychomet-
rics, reproducibility of results

A grant from the American Physical Therapy Associa-
tion supported the development of this clinical practice
guideline.
Work stemming from the CPG has been presented at the
APTA Combined Sections Meetings in 2015, 2016, and
2017; the IV STEP conference in 2016; American Col-
lege of Rehabilitation Medicine Conference in 2016; and
the Missouri PT Association Conference in 2016.
not financially supported. Dr Sullivan has presented on
Outcome Measurement for the ANPT, Neuro Recovery
Network, and Rock Mountain University of Health Pro-
fessions. All authors reviewed the CPG manuscript.
Supplemental digital content is available for this article.
Direct URL citation appears in the printed text and is
provided in the HTML and PDF versions of this article
on the journal’s Web site (www.jnpt.org).

This is an open-access article distributed under the terms

Dr Moore was the Director of the Rehabilitation Mea-
sures database (www.rehabmeasures.org) and has
presented on measurement-related topics at many profes-
sional conferences. Dr Potter’s involvement as a member
of the CPG workgroup has included a variety of presenta-
tions at the APTA Combined Sections Meeting, IV STEP,
and the Missouri PT Association Spring Conference. Dr
Blankshain’s role as a graduate assistant was to perform
administrative and organizational duties for the develop-
ment of the CPG. Dr Blankshain assisted in presenting
information at CSM. Dr Kaplan’s role as a methods
consultant was limited to the beginning phases of the
guideline development process. Her later participation as
an author was not financially supported, and she did not
participate in the choice of measures or the appraisal of
literature. Ms O’Dwyer’s participation as an author was
of the Creative Commons Attribution-Non Commercial-
No Derivatives License 4.0 (CCBY-NC-ND), where it is
permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or
used commercially without permission from the journal.
Correspondence: Kirsten Potter, PT, DPT, MS, Department
of Physical Therapy Education, Rockhurst University,
Kansas City, MO 64110 (Kirsten.Potter@rockhurst.edu).
©2018 The Authors. Published by Wolters Kluwer
Health, Inc. on behalf of Academy of Neurologic Physi-
cal Therapy, APTA
This CPG is registered with Prospero
(# CRD42015026608).

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 175

JNPT-D-17-00190.indd 175 15/06/18 9:56 PM

 JNPT • Volume 42, July 2018

TABLE OF CONTENTS

INTRODUCTION AND METHODS

Levels of Evidence and Grades of Recommendations................................................. 178

Summary of Action Statements................................................................................... 179
Introduction.................................................................................................................. 181
Methods........................................................................................................................ 182

OUTCOME MEASURE RECOMMENDATIONS

The Core Set of Outcome Measures for Neurologic Physical Therapy....................... 191
Action Statement 1: Static and Dynamic Sitting and Standing Balance Assessment.... 191
Action Statement 2: Walking Balance Assessment...................................................... 195
Action Statement 3: Balance Confidence Assessment................................................. 197
Action Statement 4: Walking Speed Assessment......................................................... 199
Action Statement 5: Walking Distance Assessment.................................................... 203
Action Statement 6: Transfer Assessment.................................................................... 207
Action Statement 7: Documentation of Patient Goals................................................. 208
Action Statement 8: Use of the Core Set of Outcome Measures................................. 209
Action Statement 9: Discuss Outcome Measure Results and Use
Collaborative/Shared Decision-Making With Patients................................................ 211
Guideline Implementation Recommendations............................................................. 212
Summary of Research Recommendations................................................................... 215

ACKNOWLEDGMENTS AND REFERENCES

Acknowledgments........................................................................................................ 217
References.................................................................................................................... 217

TABLES

Table 1: Levels of Evidence......................................................................................... 178

Table 2: Grades of Recommendations......................................................................... 178
Table 3: Outline of the CPG Process........................................................................... 183
Table 4: Inclusion and Exclusion Criteria for Article Review..................................... 187

176 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 176 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

Table 5: COSMIN Ratings for Strength of Statistics................................................... 189

Table 6: Process Used to Make Recommendations..................................................... 190
Table 7: Evidence Table, Berg Balance Scale.............................................................. 192
Table 8: Evidence Table, Functional Gait Assessment................................................. 196
Table 9: Evidence Table, Activities-specific Balance Confidence............................... 198
Table 10: Evidence Table, 10 meter Walk Test............................................................. 201
Table 11: Evidence Table, 6-Minute Walk Test............................................................ 205
Table 12: Evidence Table, 5 Times Sit-to-Stand.......................................................... 208

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 177

JNPT-D-17-00190.indd 177 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018

LEVELS OF EVIDENCE AND GRADE OF RECOMMENDATIONS

This clinical practice guideline (CPG) is intended to be a
guide for rehabilitation management of adults with neu-
rologic conditions and to inform outcome measurement
research. The CPG applies to all adult patients with neuro-
logic conditions, including those with acute (ie, <6 months
since onset/diagnosis), chronic stable (ie, >6 months since
onset/diagnosis, but not expected to worsen with time), and
chronic progressive (ie, > 6 months since onset/diagnosis,
but with the potential to experience additional symptoms or
functional changes). Clinicians and organizations should in-
terpret these recommendations in the context of the patient’s
situation, clinical practice, and potential for harm. The meth-
odology used in this CPG, including the critical appraisal
and assignment of levels of evidence and strength of the
recommendations, was derived from the COnsensus-based
Standards for the selection of health Measurement INstru-
ments (COSMIN) checklist,1-5 recommendations from the
APTA, and is in accordance with internationally accepted
methodologies for evidence-based practice. This CPG is or-
ganized to present the level of evidence definitions and the
grades of recommendations (Tables 1 and 2, respectively),
clear and implementable recommendations in the form of
9 action statements, an introduction and description of the
need for this CPG, and a standardized profile for each action
statement that meets the Institute of Medicine’s criteria for
transparency of the CPG.6 The 9 action statements include
recommendations for the core set of measures, use of the
core set, and collaborative decision-making. Research rec-
ommendations are included in the action statement profiles
and summarized at the end of the CPG.
Each article included in this CPG was appraised by 2
reviewers, and assigned a level of evidence by the guideline
development group (GDG). The grading criteria to deter-
mine the level of evidence that supports the recommenda-
tions are described in Table 1. These criteria, recommended
by the Academy of Neurologic Physical Therapy (ANPT),
were modified to accommodate descriptions of studies of
psychometric properties. Levels I and II differentiate stron-
ger from weaker studies by integrating the quality of the
research design and/or reporting of the study,7 as well as
the strength of the psychometric data.8,9 The criteria for the
grades of recommendation assigned to each action state-
ment are provided in Table 2. The grade reflects the over-
all strength of the evidence available to support the action
statement. Throughout the CPG, each action statement is
preceded by a letter grade indicating the strength of the rec-
ommendation, followed by the statement and summary of
the supporting evidence.

TABLE 1. Levels of Evidence

I Level of evidence rating I: Evidence obtained from at
least one high-quality (>50% critical appraisal score)
study of psychometric properties
II Level of evidence rating II: Evidence obtained from
multiple, lesser quality (<50% critical appraisal
score) studies of psychometric properties
III Level of evidence rating III: Evidence obtained from
one lesser quality (<50% critical appraisal score)
study of psychometric properties
IV Not applicable to studies of psychometric properties
V Expert opinion (or best practice)

TABLE 2. Grades of Recommendations

GRADE RECOMMENDATION
A Strong evidence
B Moderate evidence
C Weak evidence
P Practice
R Research
STRENGTH OF RECOMMENDATION
A preponderance of level I studies, but least 1 level I study directly on the topic supports
the recommendation
A preponderance of level II studies, but at least 1 level II study directly on the topic
supports the recommendation
A preponderance of level III studies, but at least 1 level III study directly on the topic
supports the recommendation
Best practice based on expert opinion (review papers, white papers, consensus documents)
developed by various methodologies (e.g., Delphi and RAND) and the clinical experience
of the guideline development group
An absence of research on the topic, or conclusions from existing studies on the topic are
in disagreement

178 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 178 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
SUMMARY OF ACTION STATEMENTS
A. Action Statement 1: STATIC AND DYNAMIC SIT-
TING AND STANDING BALANCE ASSESSMENT.
Clinicians should use the Berg Balance Scale (BBS) for
adults with neurologic conditions who have goals to im-
prove static and dynamic sitting and standing balance and
have the capacity to change in this area. The BBS should be
administered under the same test conditions using the proto-
col recommended by the CPG Knowledge Translation (KT)
Committee at admission, and discharge, and when feasible,
between these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
B. Action Statement 2: WALKING BALANCE ASSESS-
MENT. Clinicians should use the Functional Gait Assess-
ment (FGA) for adults with neurologic conditions who have
goals to improve balance while walking and have the capacity
to change in this area. The FGA should be administered un-
der the same test conditions using the protocol recommended
by the CPG KT Committee at admission, and discharge, and
when feasible, between these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: moderate
A.  Action Statement 3: BALANCE CONFIDENCE AS-
SESSMENT. Clinicians should use the Activities-specific
Balance Confidence (ABC) Scale to assess self-reported
changes in balance confidence in adults with neurologic
conditions who have goals and the capacity to change in this
area. The ABC should be administered under the same test
conditions using the protocol recommended by the CPG KT
Committee at admission, discharge, and, when feasible, be-
tween these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
B. Action Statement 4: WALKING SPEED ASSESS-
MENT. Clinicians should use the 10 meter Walk Test (10mWT)
for adults with neurologic conditions who have goals to im-
prove walking speed and have the capacity to change in this
area. The 10mWT should be administered (per the protocol by
Steffen and Seney,10 as adapted by the CPG KT Committee)
under the same test conditions at admission, and discharge,
and when feasible, between these periods for patients with:
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 179
JNPT-D-17-00190.indd 179
• Acute conditions: Evidence quality: V; recommenda-
tion strength: best practice
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
B. Action Statement 5: WALKING DISTANCE AS-
SESSMENT. Clinicians should use the 6-Minute Walk Test
(6MWT) for adults with neurologic conditions who have
goals to improve walking distance and the capacity to change
in this area. The 6MWT should be administered (per the
Quinn et al protocol,11 as adapted by the CPG KT Committee)
under the same test conditions at admission, and discharge,
and when feasible, between these periods for patients with:
• Acute conditions: Evidence quality: V; recommenda-
tion strength: best practice
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: moderate
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
P.  Action Statement 6: TRANSFER ASSESSMENT. Cli-
nicians should document the transfer ability of adults with
neurologic conditions who have goals to improve transfers
and have the capacity to change. Documentation should
include the type of transfer, level of required assistance,
equipment or context adaptations, and time to complete. In
patients who have goals and the capacity to improve sit-to-
stand transfers, the 5 Times Sit-to-Stand (5TSTS) may be
used. The 5TSTS and documentation of other transfers may
be administered under the same test conditions using the
protocol recommended by the CPG KT Committee at admis-
sion, and discharge, and when feasible, between these peri-
ods for adult patients with neurologic conditions (Evidence
quality: V; recommendation strength: best practice).
P. Action Statement 7: DOCUMENTATION OF PA-
TIENT GOALS. Clinicians should document patient-stated
goals and monitor changes in individuals with neurologic
conditions, using an outcome measure (OM) such as the
Goal Attainment Scale (GAS), reporting the task, the per-
formance conditions, and the time to complete or level of in-
dependence desired. Patient goals should be documented at
least 2 times, at admission and discharge, and, when feasible,
between these testing periods (Evidence quality: V; recom-
mendation strength: best practice).
B. Action Statement 8: USE OF THE CORE SET OF
OUTCOME MEASURES. Clinicians should use and doc-
ument the OMs in the core set to assess changes over time.
The core set includes the BBS, FGA, ABC, 10mWT, 6MWT,
and 5TSTS, and the recommended patient goal assessment
for adults who are undergoing neurologic physical therapy.
The core set should be administered with patients who have
goals and the capacity to improve transfers, balance, and/or
09/06/18 2:22 PM

gait. In cases when a patient cannot complete one or more
core set OMs (eg, a patient who is unable to walk; thus, can-
not complete the 10mWT or the 6MWT), a score of 0 should
be documented. The core set should be administered under
the same test conditions at least 2 times, at admission and
discharge, and when feasible between these periods (Evi-
dence quality: II; recommendation strength: moderate).
P. Action Statement 9: DISCUSS OUTCOME MEA-
SURE RESULTS AND USE COLLABORATIVE/
SHARED DECISION-MAKING WITH PATIENTS. Cli-
nicians should discuss the purpose of OMs, OM results, and
how these results influence treatment options with patients
180 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 180
JNPT • Volume 42, July 2018
undergoing neurologic physical therapy. Collaboratively, the
clinician and the patient should decide how these data should
inform the plan of care (Evidence quality: V; recommenda-
tion strength: best practice).
These guidelines were issued in 2018 based on the scientific
literature published before March 2016. These guidelines
will be considered for review by 2023, or sooner if new evi-
dence becomes available. The ANPT will oversee the pro-
cess and methodology for updating the CPG. The GDG will
work collaboratively with the ANPT Evidence-Based Guide-
line Committee. Any updates to the guidelines in the interim
period will be noted on the ANPT Web site.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
INTRODUCTION
Purpose of Clinical Practice Guidelines
The APTA and the ANPT support the use of CPGs, as they
provide therapists with evidence-based recommendations
to guide clinical decision-making.12 This CPG pertains to
the examination of patients with neurologic conditions.
Per the Guide to Physical Therapist Practice,13 the physi-
cal therapy examination consists of 3 components: history,
systems review, and tests and measures. Using standard-
ized tests and measures is recommended, and selection of
these measures is informed by their psychometric proper-
ties and clinical utility. Standardized tests and measures
may be used to predict and diagnose, discriminate, and
assess changes over time. Measuring outcomes is also
emphasized in the Guide to Physical Therapist Practice.13
The term “outcome measure” is used to refer to a stan-
dardized test or measure that is used to monitor changes
in a specific construct (eg, gait function) during an episode
of care. Various terms are used in the literature related to
OMs, including standardized assessments, instruments,
and tools. OMs exist and can be used for assessment at
any level of the International Classification of Function,
Disability, and Health (ICF),14 including body function
and structure, activity, and participation. The focus of this
CPG is to describe evidence that supports the use of spe-
cific standardized measures (both performance-based and
self/patient-reported),15,16 and the term “OM” is used to
describe these measures. Furthermore, this CPG identifies
gaps in the research related to OMs that may be used in
adult neurologic rehabilitation.
The recommendations presented in this CPG follow the
efforts of the ANPT to develop measurement recommenda-
tions as part of the Evidence Database to Guide Effective-
ness (EDGE) initiative. From 2009 to 2015, 6 ANPT EDGE
task forces identified standardized tests and measures, in-
cluding OMs, for use in several patient populations (stroke,
multiple sclerosis, Parkinson disease, traumatic brain injury,
spinal cord injury, and vestibular dysfunction). These task
forces aimed to enhance the quality of care and decrease
unwarranted variation in practice by recommending stan-
dardized tests and measures for each condition. The EDGE
process included a literature review, and a synthesis of psy-
chometric properties and clinical utility data. Using a modi-
fied Delphi process, recommendations were made for the
use of 243 standardized measures in clinical practice, edu-
cation, and research. Each task force developed recommen-
dations for specific patient subgroups (eg, acute, subacute,
and chronic stroke) and across a variety of health care set-
tings.17-21 This work may have enhanced the quality of reha-
bilitation by providing clinicians with a substantial amount
of summarized information for each OM for the target pa-
tient population. However, due to the large number of OMs
reviewed and recommended, it is unlikely that the goal of
decreasing unwarranted variation in practice was achieved.
Furthermore, the recommendations provided by each task
force were focused on specific patient populations and not
intended for use across all populations of patients with neu-
rologic conditions.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 181
JNPT-D-17-00190.indd 181
Background and Need for a Core Set of OMs
In 2012, the Institute of Medicine recommended that health
care organizations build a learning health system that col-
lects and analyzes standardized measurement data in clini-
cal practice to measure patients’ perspectives, improve care
delivery, increase transparency of outcomes, link clinicians’
performance to patient outcomes and internal and exter-
nal benchmarks, manage patient care, improve processes,
strengthen public health, and generate knowledge.22 The core
set of OMs recommended in this CPG provides a first and
necessary step toward achieving the learning health system
vision in neurologic physical therapy. Using OMs through-
out a patient’s episode of care is considered good clinical
practice23 and may enhance care by contributing to a more
thorough examination and tailored care plan.24 OMs can be
used to monitor changes in a patient’s status over time, quan-
tify observations and patient-reported function over time,
enhance communication between care settings,15,16 and in-
crease the efficiency of the delivery of patient care.25 OMs
can also help managers measure costs,26 identify “at-risk”
patients,27 enhance reimbursement,28 and compare outcomes
among clinicians and settings.27 Use of a common set of
OMs promotes best practice by allowing direct comparisons
of outcomes associated with different interventions.29 Wide-
spread adoption of a core set of OMs across clinical settings
would support the Institute of Medicine recommendations,
and may enable robust data collection efforts to rapidly ad-
vance clinical practice through the development of practice-
based evidence.30
Despite reports describing the benefits of routine use
of OMs, they are inconsistently used in rehabilitation.23,24,31
Reported barriers include time, available equipment, per-
ceptions of patient burden, clinician attitude/knowledge/
skill, lack of financial compensation, and poor availability
of measures.24,32-36 Current practice is characterized by great
variation in the use of OMs, few mandates for the use of spe-
cific OMs, and a lack of recommendations for a core set of
OMs across neurologic conditions. With the exception of the
Functional Independence Measure, which is required in in-
patient rehabilitation, no measure (or group of measures) is
required for all patients with neurologic conditions receiving
physical therapy. Yet, the Centers for Medicare & Medicaid
Services (CMS) now requires the use of objective measures
of function in outpatient physical therapy practice.37 The
APTA, through PTNow, has identified multiple OMs that
can be used to meet the requirements set by CMS.38 Howev-
er, to date, a core set of OMs has not been identified for use
in neurologic physical therapy practice; thus, the primary
purpose of this CPG is to identify a core set of OMs for use
with adults who have neurologic conditions.
Scope
This CPG aims to standardize practice by providing reha-
bilitation clinicians with recommendations for a core set of
OMs for adults with neurologic conditions that should be
routinely used in all settings. Based on input provided by
physical therapists (PTs) and consumers of physical therapy,
the core set focuses on the highest priority constructs of bal-
ance, gait, transfers, and patient-stated goals. Use of the core
09/06/18 2:22 PM

set should increase standardization of OM selection and ad-
ministration and provide the ability to measure changes in a
patient’s status over time. In addition, greater standardization
of OMs should enhance effective communication among
providers and with patients/caregivers, facilitate intervention
effectiveness analysis and programmatic assessment within
and among facilities, and may improve reimbursement.
This CPG focuses on adult patients (older than 18 years), of
either sex, who are undergoing physical therapy services for
treatment of a neurologic condition (eg, an injury or disease
to the central or peripheral nervous system). The CPG action
statements apply:
• When examining balance, gait, transfers, and when set-
ting patient goals.
• In all health care settings or contexts, across the contin-
uum of care settings, including but not limited to acute
care hospitals, inpatient and outpatient rehabilitation,
skilled nursing facilities, and home health care.
The specific goals of this CPG are to:
1. Standardize the use of a core set of OMs to assess
changes over time in neurologic physical therapy with-
in and among facilities.
2. Facilitate comparison of outcomes across interven-
tions, providers, and patients within and among di-
agnostic groups through the use of a common set of
measures.
3. Facilitate the development of practice-based evidence
by standardizing the use of OMs for patients with neu-
rologic conditions to enable the creation and analysis
of large data sets.
4. Improve quality of care by standardizing data elements
to answer important clinical questions (eg, identifica-
tion of treatment responders vs nonresponders).
5. Ensure systematic and standardized documentation of
OMs to help justify a patient’s need for therapy and to
inform policy. Improved documentation of OMs could
be used to clarify and improve policies related to reim-
bursement and access to care.
6. Identify gaps in the literature related to OMs in adult
neurologic rehabilitation. This may prompt researchers
to rigorously study the psychometric properties of un-
tested OMs or develop new measures to meet clinical
needs.
7. Enhance the education of future rehabilitation provid-
ers by informing curricular decisions about the core set
of OMs to include in entry-level and residency physi-
cal therapy education.
Statement of Intent
Primarily intended for application in adult neurologic reha-
bilitation, this CPG may be useful to rehabilitation profes-
sionals including PTs, physical therapist assistants (PTAs),
occupational therapists, and occupational therapy assistants
who select and administer OMs; therapeutic recreation
therapists, physicians, and nurses who are interested in un-
derstanding the use of OMs in rehabilitation; educators who
make decisions about academic curricula; researchers who
select or study OMs; regulatory bodies and policy mak-
ers; professional associations (eg, the APTA, APTA Acad-
emies of Neurology and Geriatrics, Canadian Physiotherapy
182 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 182
JNPT • Volume 42, July 2018
Association, and World Confederation of Physical Therapy);
consumer organizations and associations (eg, the National
Stroke Association and the Multiple Sclerosis Society);
health care administrators, and third-party payers. This CPG
does not serve as a legal standard of care or mandate. It pro-
vides recommendations for the use of a core set of OMs in
clinical practice, based on a rigorous systematic review and
critical appraisal process. Adherence to these guidelines
will not guarantee a positive outcome in care; however, it is
anticipated that the CPG will improve quality of care when
implemented. Furthermore, this CPG does not provide a
comprehensive review of all OMs. Rather it focuses exclu-
sively on OMs in the constructs of balance, gait, transfers,
and patient-stated goals. The appropriate use of the recom-
mended OMs in clinical practice is ultimately the decision
of each clinician and patient/significant other. If these OMs
are not used, the rationale for the use of other OMs should
be documented. We intend for the OM results to be shared
with patients and significant others during adult neurologic
rehabilitation. Collaboratively, clinicians and patients should
decide how the results should guide the plan of care.
METHODS
The steps outlining the process of review and determination
of the core set are shown in Table 3. The GDG consisted of 3
PTs (J.M., K.P., and J.S.) with expertise in outcome measure-
ment. Two of the team leaders (J.S. and K.P.) served as Chair
of the ANPT’s EDGE task forces for stroke18 and multiple
sclerosis,17 respectively. The third (J.M.) led the development
of the Rehabilitation Measures Database39 and has expertise
in knowledge translation. The GDG proposed the CPG on
the core set of OMs to the ANPT’s Board of Directors, who
approved the proposal. The GDG attended the APTA Clini-
cal Practice Guideline Workshop in July 2013 and received
funding from the APTA in December 2013 to support the
CPG’s development.
The GDG recruited 2 consultants including a method-
ologist (S.K.) to provide advice on conducting the system-
atic review and writing the CPG, and a psychometrician
(C.H.C.—see Acknowledgments) to assist with survey
development, modifying COSMIN to create a critical ap-
praisal tool, and data analysis. A medical reference librar-
ian (L.O.) led the literature search process and assisted
with writing the CPG. A doctor of physical therapy student
(K.B.) functioned as a graduate assistant who assisted with
the development and management of article and data stor-
age systems, coordinated communication between the GDG
and article reviewers, and assisted with data analysis and
writing of the CPG.
The GDG also recruited an expert panel consisting of an
international and diverse group of stakeholders who provid-
ed feedback about the scope, process, and final CPG recom-
mendations. The expert panel, identified in the Acknowledg-
ments, included consumers (ie, patients) who had received
neurologic physical therapy; PTs (novice and experienced)
who were members of the ANPT; other rehabilitation pro-
fessionals (neurologists, occupational therapists, speech/lan-
guage pathologists, neuropsychologists); representatives of
professional associations; health care administrators; journal
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

TABLE 3. Outline of the CPG Process

STEP GENERAL PROCESS SPECIFIC TASKS
1 Recruitment of consultants, medical librarian, graduate assistant, and expert
Team recruitment
panel members.
2 Development of surveys to identify scope and focus of the CPG; IRB approval
Identification of CPG scope and obtained.
3 focus Administered surveys to consumers and PTs; analyzed data to determine the
CPG scope in areas of balance, gait, transfers, and patient-stated goals.
4 Initial identification of OMs Identification and evaluation of OMs reviewed by the 6 EDGE task forces. The
considered for the CPG measures met the following criteria to be considered for inclusion in the core set:
(a) received a rating of ≥2 by the EDGE task force(s); (b) generic (eg, not condi-
tion-specific); (c) relevant to the scope of the CPG (balance, gait, transfers, and pa-
tient-stated goals); (d) availability of data in at least 2 neurologic populations; (e)
able to track patient change over time; (f) high clinical utility (ie, free, <20 min
to administer, and no specialized equipment); (g) published data on reliability and
data to assess change (coincided with the literature review, described later).
5 Literature search for articles pertaining to the OMs reviewed by EDGE task
force(s) with databases searched from article inception through April 2015.
6 Literature reviews, identification of Title and abstract review. Two members of the GDG reviewed each article (third
additional OMs, and review of OMs member serving as tie breaker when needed). Inclusion criteria included English
for inclusion in the CPG language, subjects older than 18 years with adult-onset neurologic condition,
studied reliability and/or psychometric properties that assess change, and sample
size ≥30 (or power analysis conducted and sample size met).
7 Full-text article review using inclusion criteria described previously. One mem-
ber of the GDG reviewed each article, sorting each into folders in accordance
with the OM studied (eg, Berg Balance Scale) and the psychometric property
studied. Inclusion criteria described previously.
8 Review of literature for newly identified OMs. Literature search for articles
pertaining to the additional OMs identified with databases searched from article
inception through April 2015.
9 Title and abstract review of articles pertaining to additional OMs identified;
process described previously.
10 Full-text article review of articles pertaining to additional OMs identified;
process described previously.
11 Final literature search to identify articles published between April 2015 and
March 2016; articles reviewed using the process described previously.
12 Use and modification of COSMIN to COSMIN selected and modified to meet the needs of the CPG and process for
rate article methodological quality scoring COSMIN was established.
13 Article reviewers recruited.
14 Article reviewer recruitment and Online program developed to train article reviewers to use modified COSMIN.
training Each potential reviewer completed the training program and analyzed one article
using modified COSMIN; those achieving a score of 80% were invited to serve
as an article reviewer.
15 Two reviewers scored each article using modified COSMIN administered via
SurveyMonkey.
16 Critical appraisal of articles Graduate assistant exported data from SurveyMonkey to Excel spreadsheet and
compared data from the 2 reviewers. Inconsistencies addressed by initial review-
ers when able; if continued inconsistencies existed, the GDG member solved the
conflict.
17 Scores for each section of COSMIN were calculated. Total article methodologi-
Scoring of article methodological
cal score calculated based on lowest section score received for the given article.
quality
Level I or II article rating determined.
18 COSMIN recommendations for scoring strength of psychometrics adopted and
Scoring of psychometric properties
used to score reliability and measurement error from each article for each OM.
(continues )

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 183

JNPT-D-17-00190.indd 183 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018

TABLE 3. Outline of the CPG Process (Continued )

STEP GENERAL PROCESS SPECIFIC TASKS
19 The GDG identified process for review of OM data for inclusion in core set and
set criteria for strong vs moderate recommendations.
20 Analysis of OM data across articles Combined information from all articles on a given measure, as related to psy-
chometric properties studied, strength of psychometric data, patient population
studied, and category (acute, chronic stable, and chronic progressive).
21 Recruitment of KT team KT team recruited.
21 Action statement profile generation Action statements creation using BridgeWiz.
22 Review of CPG CPG reviewed by ANPT Evidence-Based Documents Advisory Committee
and CPG Expert Panel, and will be reviewed APTA PTNow using Appraisal
of Guidelines, Research, and Evaluation (AGREE II) tool.
23 CPG reviewed by KT committee using Guideline Implementability Appraisal
Tool (GLIA)
24 Public review of the CPG with feedback submitted through SurveyMonkey.
Abbreviations: AGREE, Appraisal of Guidelines for Research and Evaluation; COSMIN, Consensus-based Standards for the Selection of Health Measurement
Instruments; CPG, clinical practice guideline; EDGE, Evidence Database to Guide Effectiveness; GDG, guideline development group; IRB, institutional review
board; KT, Knowledge Translation; OM, outcome measure; PT, physical therapist.

editors; and experts in OMs, knowledge translation, policy,
and reimbursement.
Methods to Determine the CPG Scope
To identify the scope and focus of the CPG, the GDG devel-
oped and administered separate online surveys to consum-
ers of neurologic physical therapy services and to ANPT
members. Surveys were administered via SurveyMonkey
and focused on the use of OMs during physical therapy ex-
amination and care. Before dissemination, the surveys were
approved by the Institutional Review Boards at Northwest-
ern University (Chicago, Illinois) and Rockhurst University
(Kansas City, Missouri).
Consumer Survey
An invitation to consumers of neurologic physical therapy
was distributed through the Clinical Neuroscience Re-
search Registry at the Rehabilitation Institute of Chicago
and Northwestern University, Heartland Chapter of the Na-
tional Parkinson’s Disease Foundation, and the Mid America
Chapter of the National Multiple Sclerosis Society. Par-
ticipants included individuals with email access who were
registered in the research and/or email databases of these
organizations. Approximately 828 people with stroke, 395
with spinal cord injury (SCI), 11 635 with multiple sclerosis
(MS), and 2500 with Parkinson disease (PD) received an in-
vitation to participate. The invitation provided a link to the
survey, and indicated that participation was optional. To be
eligible, consumer participants were required to have a med-
ically diagnosed neurologic condition, have received physi-
cal therapy services, be 18 years or older, English-speaking,
and have email access. Participants confirmed that they met
these inclusion criteria and provided informed consent on
the first page of the survey.
The 21-item survey included questions pertaining to
neurologic physical therapy, including the:
• reason for seeking services;
• frequency, duration, and setting of services;
184 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
• perceived importance of improving function in various
areas (eg, gait and decrease fatigue);
• constructs (eg, balance) examined using tests per-
formed by the PT;
• formats of tests used in clinical settings (eg, question-
naires and performance tests);
• frequency and duration of testing;
• information provided by the PT regarding the purpose
and results of tests;
• perceived importance of the tests;
• recommendations for therapy time that should be dedi-
cated to testing; and
• satisfaction with services and information received
about the tests conducted.
Academy of Neurologic Physical Therapy
Member Survey
Approximately 5000 PT and PTA members of the ANPT
were invited to participate in the survey. Inclusion criteria
required that the PT or PTA be licensed, college educated,
and have email access. A link to the survey was sent via e-
mail through the ANPT’s listserv and electronic newsletter.
Survey participation was optional and the respondent pro-
vided informed consent prior to survey initiation.
The ANPT member survey included a maximum of 65
questions; the number and type of questions answered var-
ied by the participant’s responses. Survey logic ensured that
questions received by each respondent were relevant to the
individual’s role (eg, clinician or educator/researcher/other).
The survey consisted of 3 sections: demographic data, a core
set needs assessment, and use of OMs in practice. Demo-
graphic data included primary and professional roles, experi-
ence (eg, number of years of experience, certifications, and
training on OMs), APTA and ANPT membership, education,
primary employment setting, and willingness to use a core set
of OMs. The core set needs assessment questions captured
the respondent’s understanding of core sets and their use; im-
portance of having a core set; types of OMs recommended for

JNPT-D-17-00190.indd 184 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
the core set; representation of the ICF domains and specific
items (eg, aerobic capacity) in the core set; time and money to
support use of the core set; and benefits and potential impact
of the core set. Lastly, questions inquired about use of OMs in
practice. Clinician respondents were asked about current use
of OMs in practice, whereas the educators, researchers, and
other respondents (eg, managers) were asked to provide their
thoughts on what should be measured in practice.
De-identified aggregate data from both surveys were an-
alyzed using descriptive statistics. Data were used to inform
the scope and focus of the CPG, particularly to identify the
highest priorities for each sample group.
Survey Results
A total of 518 individuals completed the survey (303 PTs and
215 consumers). The PT respondents reported their primary
position as either a clinician (69%) or educator (24%). They
were experienced, with 45% having greater than 15 years
of experience and 54% holding American Board of Physi-
cal Therapy Specialties certification. The majority were em-
ployed either in an outpatient (46%) or inpatient rehab set-
ting (28%). The neurologic conditions experienced by the
consumers included MS (49%), stroke (34%), or SCI (14%).
Most received outpatient physical therapy (70%), and some
received services in inpatient rehabilitation (21%).
Survey results showed that 94% of clinicians use OMs
in clinical practice. The majority reported having 30 to
60 minutes to conduct examinations at admission (78%),
interim (53%), and discharge (52%). Almost all (98%) re-
ported that a core set is either essential (65%) or desirable
(33%), and 91% indicated they were very willing (58%) or
willing (33%) to incorporate a core set of OMs into practice.
Regarding the maximum amount of time that should be used
to administer OMs, the greatest number (43%) answered 15
to 29 minutes. All stated the core set should include OMs
related to the ICF domain of activity, with 98% scoring this
as essential. Clinicians scored the following constructs as es-
sential to include in the core set: balance (98%), gait (95%),
patient-stated goals (82%), and transfers (81%).
Results from the consumer survey showed that they also
value the use of tests in their care; 59% scored tests as very
important and 35% as somewhat important. Of note, con-
sumers identified that they were referred to physical ther-
apy due to walking (83%) and balance difficulties (68%),
with approximately 90% indicating it was very important to
improve walking and balance.
Survey results indicated that OMs that assess changes in
balance and gait are important to both clinicians and consum-
ers and should be included in the core set. In addition, the
PT survey indicated OMs related to patient-stated goals and
transfers were also important for inclusion in the core set.
Selection of Measures to Consider for the CPG
Two sets of measures were evaluated for the inclusion in the
CPG—(1) all measures (n = 243) that had been reviewed
by the 6 ANPT EDGE task forces,17-21 and (2) new measures
(n = 67) identified during the literature search—that were
not originally reviewed by the EDGE task forces and were
studied in any adult neurologic population. During each
step of the review process, the GDG reached consensus on
decisions about measure inclusion.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 185
JNPT-D-17-00190.indd 185
Appendix 1 provides a list of measures reviewed for in-
clusion in the CPG (see Supplemental Digital Content 2,
Appendix 1, available at: http://links.lww.com/JNPT/A215).
Details about the literature search are provided in the section
titled Literature Search.
EDGE-Reviewed Measures
Step 1. Identification of Standardized Measures
With EDGE Ratings of 2 to 4/4
All 243 standardized measures reviewed by the ANPT
EDGE task forces were considered for inclusion in the CPG.
The EDGE task forces used a 1- to 4-point rating scale to
make recommendations for measures in categories such
as condition acuity, severity, and site of care.21 A rating of
“4” indicated that the measure had excellent psychometric
properties and clinical utility in the target condition; a “1”
rating indicated poor psychometrics (inadequate reliabil-
ity or validity) or limited clinical utility (extensive testing
time, unusual or expensive equipment, costs to administer,
etc).17,18 In step 1, measures that received a “1” rating across
all categories and EDGE groups were eliminated. A total of
222 standardized measures were retained.
Step 2. Identification of Generic/Not Condition-
Specific Standardized Measures
To identify measures that could be used across neurologic
populations, condition-specific measures (eg, Stroke Impact
Scale) were eliminated. One hundred forty-six of the 222
standardized measures were retained.
Step 3. Identification of Standardized Measures
That Address the CPG Target Constructs
The remaining measures were evaluated relative to the con-
structs of balance, gait, transfers, and patient-stated goals.
A measure was eliminated if fewer than 75% of the items
or questions assessed these constructs. Fifty-four of the 146
measures were retained.
Step 4. Identification of Standardized Measures
Used in 2 or More Neurologic Populations
To identify OMs that were appropriate for use across neu-
rologic conditions, measures were eliminated that did not
have published psychometric data in at least 2 neurologic
populations. Forty-one of the 54 standardized measures were
retained.
Step 5. Identification of Standardized Measures
That Evaluate Change
Each measure was evaluated to determine whether it could
be used to demonstrate changes over time. The availability of
psychometric properties that assess changes (eg, minimum
detectable change and minimum clinically important differ-
ence) for each measure was ascertained. All 41 standardized
measures were retained.
Step 6. Identification of Measures With Excellent
Clinical Utility
Approximately 85% of PT survey respondents indicated that
45 minutes or less should be spent on OM administration,
with 63% indicating the maximum time spent on measure
09/06/18 2:22 PM

administration should be less than 30 minutes. In addition,
71% indicated the OM should cost $100 or less. Therefore, the
GDG decided that, to be included, an OM had to be free, require
equipment commonly available in a clinic, and take 20 minutes
or less to administer. Thirty-five of the 41 OMs were retained.
Step 7. Identification of Candidate OMs
Step 7 followed a literature search of the 35 OMs that met
the criteria described in steps 1 through 6. Following the lit-
erature search, title/abstract screening, and full-text review,
each OM was evaluated to determine whether reliability and
data to support interpretation of results (eg, minimal detect-
able change [MDC] and minimal clinically important differ-
ence [MCID]) were available in at least one article that met
inclusion criteria for the CPG. The remaining 16 measures
and relevant literature proceeded to a critical appraisal with
data extraction via the modified COSMIN checklist5 by the
trained reviewer pool.
New Measures
During the initial literature search (including the title/ab-
stract and full-text review), the GDG identified 67 additional
measures that were not previously reviewed by EDGE. These
measures were reviewed using the process described in steps
2 through 7 previously. The measures retained during each
step are described next.
Step 1: Not applicable because these measures were not
reviewed by the EDGE task forces.
Step 2: 65 of the 67 new measures were retained; 2 were
excluded because they were condition-specific.
Step 3: 52 of the 65 measures were retained; 13 were exclud-
ed because fewer than 75% of the test items pertained to
gait, balance, transfers, and patient-stated goals.
Step 4: 13 of the 52 measures were retained; 39 were ex-
cluded because there were no published data in 2 or more
neurologic populations.
Step 5: 12 of the 13 measures were retained; 1 was excluded
because there were no data on psychometric properties
that indicated the measure could detect changes over
time.
Step 6: 10 of the 12 measures were retained; 2 were excluded
because they did not meet the clinical utility criteria.
Step 7: 2 of the 10 measures were retained and relevant lit-
erature proceeded to a full-text review and data extraction
by the trained reviewer pool using the modified COSMIN
checklist.5 Eight were eliminated because they lacked
data demonstrating reliability and supporting interpreta-
tion of the results (eg, MDC and MCID).
Literature Search
A medical librarian (L.O.) collaborated with the GDG to
develop the search strategies to identify articles related to
each of the OMs of interest. The study types included meta-
analyses, systematic reviews, and psychometric studies in
the following databases: PubMed MEDLINE, Embase, Co-
chrane Central Register of Controlled Trials, and CINAHL.
Search strategies for the Embase, CENTRAL, and CINAHL
databases were adapted from the PubMed MEDLINE search
strategy. A validated search filter, developed by COSMIN
for finding studies on OMs, in conjunction with the search
186 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 186
JNPT • Volume 42, July 2018
strategies in PubMed, was used.40 A validated version of the
filter was also used for the Embase search (developed by E.
P. Jansma, Medical Library, VU University, Amsterdam, the
Netherlands). The search strategy is depicted in Appendix 2
(see Supplemental Digital Content 3, available at: http://
links.lww.com/JNPT/A216).
The initial searches focused on articles pertaining to the
EDGE-reviewed OMs and were performed in April 2015,
October 2015, and December 2015, resulting in a total of
18 007 articles. All databases were searched back to their in-
ception, and no language or date limits were applied. This
literature review is depicted in Appendix 2. After duplicates
were removed, 12 088 articles remained. To be included, the
study was published in English, studied the English lan-
guage version of the OM, and assessed reliability and or val-
ues support interpretation of the results (eg, standard error
of measurement [SEM], MDC, and MCID). In accordance
with COSMIN, the sample size needed to be a minimum of
30; articles with a sample size less than 30 were acceptable if
a power analysis was done and the required sample size was
met. Lastly, study participants needed to be adults (18 years
or older) with a neurologic condition. Table 4 outlines the
inclusion and exclusion criteria.
The titles and abstracts of the 12 088 articles were re-
viewed by 2 of 3 GDG members, and reviewer pairs were
rotated within the GDG. The third member played the role
of tie breaker where disagreement on an article’s inclusion
occurred between the 2 initial reviewers. Following the title
and abstract review, 11 548 articles were excluded. Full-text
reviews were conducted on the remaining 540 articles; each
was reviewed by 1 GDG member using the same criteria. A
second GDG member assessed articles if questions or con-
cerns about an article were identified. Lastly, the graduate
assistant reviewed the reference lists in each article to iden-
tify any additional relevant articles. None was identified.
Follow-up literature searches using the strategies de-
scribed previously were performed in March 2016 to identify
any new articles published since April 2015; 403 articles were
identified after duplicate removal. After title and abstract re-
view, 365 articles were excluded, leaving 38 additional arti-
cles for review. The PRISMA diagram (Figure) illustrates the
article search processes used; 64 articles were included for
full-text review (see Supplemental Digital Content 4, Figure,
available at: http://links.lww.com/JNPT/A218).
Critical Appraisal Tool Development
To determine the methodological quality of the articles, the
original version of the COSMIN8,9,41,42 was modified (COS-
MIN-M). COSMIN1,3-5 provides a standard for evaluation of
the study design and statistical analysis of the psychometric
properties, including sections representing these psychomet-
ric properties: internal consistency, reliability, measurement
error, content validity, construct validity, structural validity,
hypothesis-testing, cross-cultural validity, criterion validity,
responsiveness, and interpretability. During an article review
using COSMIN-M, only the sections appraising properties
assessed in the study were completed by reviewers, using a
dichotomous (eg, yes or no) scale. For example, if a study
only reported on reliability, reviewers only completed COS-
MIN-M sections on reliability and general methodology.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
TABLE 4. Inclusion and Exclusion Criteria for Article Review
CRITERION INCLUSION
Language of article Published in English
Language of OM OM studied is not the English version
Sample size n = ≥30 or n < 30, but power analysis done and
sample size met
Conditions Acquired neurologic conditions for entire sample
If a mixed (neuro; nonneuro) must report data
separately for neuro and must meet sample size
requirement for neuro subset
Age Minimum of 18 y old
Purpose of article OM on our list
Psychometrics assessed
Psychometrics Study examined one or more of the following:
Internal consistency
Reliability
MDC
MCID
SEM
Ceiling and/or floor effects
Abbreviations: MCID, minimal clinically important difference; MDC, minimal detectable change; OM, outcome measure; SEM, standard error of measurement.
Although the original COSMIN rating scale has been modi-
fied to incorporate a 4-point scale (poor, fair, good, and ex-
cellent), the GDG selected the original version to facilitate
ease of scoring and higher reliability of the reviewers.
In consultation with the methodologists, to focus on the
purpose and intent of this CPG, the following modifications
were made to the COSMIN tool by the GDG. We retained
COSMIN questions about statistical techniques used and
results, and questions about the presence of potential study
flaws. However, the sections on internal consistency, reliabil-
ity, interpretability, and generalizability were modified to re-
duce the number of items and include only those that were
of utmost importance to determining the methodological
quality of the study. Questions relevant to the development
of the core set were also retained. For example, questions
pertaining to psychometric variables that measure changes,
such as MCID, MDC, and SEM, were retained, as these can
be used to set goals and determine treatment effectiveness.
Additional questions about specific psychometric values,
such as intraclass correlation coefficients (ICCs), and the lo-
cation of that data in the manuscript were added. Appendix
3 provides a list of measurement terms used in the CPG with
definitions (see Supplemental Digital Content 5, Appendix
3, available at: http://links.lww.com/JNPT/A217). The COS-
MIN-M generalizability section included questions pertain-
ing to the neurologic condition of the population studied (eg,
stroke and PD), acuity and stability (progressive and non-
progressive) of the condition, age and sex, and the setting in
which the study took place. A new section, labeled “general
methodology,” related to sample size, missing data, and rater
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 187
JNPT-D-17-00190.indd 187
EXCLUSION
Published in language other than English
OM studied is the non-English version
Sample size <30 and no power analysis done
Sample size <30 but insufficient to meet power
analysis requirements
Adults with congenital neuro conditions
Study focuses on nonneuro populations
Study includes subjects with neuro and nonneuro
conditions, but data reported in aggregate
Dementia
Study includes only community-dwelling elders
Sample includes individuals younger than 18 y
Systematic review
Meta-analysis
Intervention study
Does not assess one of the target psychometric
properties
training and experience was included. Reviewers completed
the COSMIN-M via an online survey Web site (SurveyMon-
key).43 Appendix 4 provides a copy of the COSMIN-M. Two
members of the GDG reviewed each article to determine and
document any reported adverse events (see Supplemental
Digital Content 6, Appendix 4, available at: http://links.lww.
com/JNPT/A219).
Reviewer Selection and Training
Article reviewers were recruited at the 2015 APTA Com-
bined Sections Meeting and via postings on the ANPT’s e-
newsletter and listserv. All applicants completed an online
reviewer training course developed by the GDG using Ar-
ticulate Storyline 2™. The training program consisted of
an overview of the CPG and the COSMIN-M, followed by
a detailed description of the methods for completing each
section of the COSMIN-M (internal consistency, reliability,
interpretability, generalizability, and general methodology).
Lastly, information was provided outlining the CPG process
and reviewer expectations.
The GDG selected one article for reviewer training and
testing, and 2 GDG members first completed the online
COSMIN-M for the article. The third GDG member served
as a tiebreaker to resolve any conflicts. The GDG’s final rat-
ings were used as a basis for the testing score agreement
with article reviewers. Each potential reviewer completed
the COSMIN-M review for 2 measures studied in this arti-
cle. To successfully complete the training and begin review-
ing articles, a reviewer needed to score 80% or more agree-
ment with the GDG score. If needed, reviewers were allowed
09/06/18 2:22 PM

a second chance to resubmit the review on the same article
(without any feedback on the previous review) and achieve a
score of 80% or more; 23 individuals successfully completed
the training to review articles.
Scoring of Methodological Quality
Two reviewers assessed the methodological quality of
each article using the online COSMIN-M (Appendix 4),
for each OM reported in the article. To avoid redundancy,
each reviewer completed the general methodology section
only once for each article. The graduate assistant exported
COSMIN-M data into an Excel spreadsheet to compare data
from the 2 reviewers. When inconsistencies were identified,
reviewers were asked to reevaluate the question and confirm
or change the original response. When inconsistencies con-
tinued, a GDG member resolved the conflict.
Once the results were finalized, the score for each sec-
tion was calculated using the percentage of “yes” responses
to the questions. Section scores were compared to inform
the overall article quality score, which reflected the score
received by the lowest scoring section. For example, if an
article received 80% for reliability and 60% for measure-
ment error, the article would receive an overall quality score
of 60%. If the overall quality score was 50% or more, the
article received a level I rating. If the score was < 50%, the
article could not receive higher than a Level II rating.
The strength of the psychometric data was determined
in accordance with COSMIN (Table 5). Relevant statisti-
cal results from each article were evaluated to determine
whether they exceeded the threshold established by COS-
MIN (Table 5). If the article received a level I rating and
had strong psychometric properties, the article received a
psychometric property rating of strong (+++). A rating of
strong (−−−) was used for level I studies where the psy-
chometric properties were below the COSMIN threshold.
Level II articles received a score of moderate (++) if the
psychometric properties met the psychometric threshold and
a moderate (−−) if the psychometric properties were below
the threshold. Ratings of strong (?) or moderate (?) were as-
signed if specific psychometric properties were not studied
(eg, where MDC was calculated, but not minimal important
change [MIC]). After this step, each article was assigned a
level of evidence and statistical strength score.
Finally, information from multiple articles on each OM
was combined, including level of evidence, strength of psy-
chometric property, the patient population studied, and the
condition category (acute, chronic stable, and chronic pro-
gressive) as depicted in Table 6 (step 4). The acute category
was defined as participants who had the condition for less than
6 months; this applied to individuals with new conditions that
were expected to improve (eg, peripheral vestibular hypofunc-
tion) or to those with potentially long-lasting, but recently di-
agnosed conditions (eg, stroke, SCI, and brain injury). The
chronic stable category was defined as more than 6-month
duration, but not expected to progress with time, applying to
participants with conditions such as stroke, SCI, or brain in-
jury diagnosed more than 6 months ago. The chronic progres-
sive category was defined as more than 6 months in duration,
but with potential to experience additional symptoms or func-
tional decline (eg, amyotrophic lateral sclerosis, MS, or PD).
188 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 188
JNPT • Volume 42, July 2018
Recommended Action Statements
Using BridgeWiz for APTA 3.0, action statements were
generated that include clear and implementable recommen-
dations, consistent with the Institute of Medicine recom-
mendations for transparency.44 The first step was to identify
OMs that demonstrated level I evidence of excellent internal
consistency and/or reliability and SEM/MDC data in 2 or
more populations and 3 condition categories (acute, chronic
stable, and chronic progressive). If a construct area did not
have an OM that met this first criterion, other OMs that dem-
onstrated level I evidence of excellent internal consistency
and/or reliability and SEM/MDC data in 2 or more popula-
tions and 2 categories were considered. Because the aim of
this CPG was to recommend a core set of OMs for use in
adult neurologic conditions, when more than one OM in a
construct area had substantial supporting evidence, the OM
with the strongest psychometric properties across diagnos-
tic groups was selected. For the construct of gait, measures
of speed and endurance were considered separately, as these
represent 2 different, yet important, aspects of gait perfor-
mance. Similarly, for balance, both performance-based and
patient-reported measures were considered separately. Only
one OM for the construct of transfers met the criteria for
consideration in the core set. Because this was a priority
area identified in our surveys, and the OM had some data to
support inclusion in the core set, a best practice recommen-
dation was made and documentation standards were recom-
mended for other types of transfers.
For patient-stated goals, no OMs were identified with
sufficient literature for recommendation in the core set.
Instead, general recommendations for documentation stan-
dards were developed. To standardize administration of OMs
in clinical practice, recommendations related to the general
OM use and OM timing were also generated. Lastly, rec-
ommendations were made related to the sharing of OM-
related information and decisions with patients. Research
recommendations (designated by R) were generated to iden-
tify missing or conflicting evidence related to using the psy-
chometric variables studied in the CPG, for OMs that should
be studied across more condition categories, and regarding
study of recommended administration protocols.
Guideline Review
1. This CPG underwent 4 formal reviews. The first review
was conducted by the GDG using 2 tools:
• The Appraisal of Guidelines for Research and Evaluation
(AGREE II)45 an instrument used to assess CPG quality
with 23 items in 6 domains. Each item is rated using a
7-point rating scale that includes specific rating criteria.
• The Guideline Implementability Appraisal v 2.0
(GLIA)46 to assess each action statement across 8 di-
mensions of implementability including executability,
decidability, validity, flexibility, effect on care processes,
measurability, novelty/innovation, and computability.
2. A second review included completion of the AGREE
II by the ANPT Evidence-Based Documents com-
mittee and CPG expert panel. Eight reviewers com-
pleted the AGREE II. The aggregate score was 94%.
The GLIA tool was completed by each member of the
ANPT-appointed Knowledge Translation Task Force
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

TABLE 5. COSMIN Ratings for Strength of Statisticsa8

LEVEL COSMIN RATING CRITERIA
I Strong (+++) Level of evidence rating I: Evidence obtained from a high-quality (≥50% critical
appraisal score) study of psychometric properties
Psychometric property rating (+++):
Internal consistency: Cronbach α ≥ 0.7
Reliability: ICC or weighted κ ≥ 0.70; Pearson’s r ≥ 0.80
Measurement error: MIC > SDC or MIC outside the LOA
Responsiveness: Floor or ceiling effect <15%
Strong (−−−) Level of evidence rating I: Evidence obtained from a high-quality (≥50% critical
appraisal score) study of psychometric properties
Psychometric property rating (−−−):
Internal consistency: Cronbach α < 0.7
Reliability: ICC or weighted κ < 0.70; Pearson’s r < .80
Measurement error: MIC ≤ SDC or MIC inside the LOA
Responsiveness: Floor or ceiling effect ≥ 15%
Strong (?) Level of evidence rating I: Evidence obtained from a high-quality (≥50% critical
appraisal score) study of psychometric properties
Psychometric property rating (?):
Internal consistency: Cronbach α not determined
Reliability: Neither ICC or weighted κ, nor Pearson’s r determined
Measurement error: MIC not defined
II Moderate (++) Level of evidence rating II: Evidence obtained from a lesser quality (<50% critical
appraisal score) study of psychometric properties
Psychometric property rating (++):
Internal consistency: Cronbach α ≥ 0.7
Reliability: ICC or weighted κ ≥ 0.70; Pearson’s r ≥ 0.80
Measurement error: MIC > SDC or MIC outside the LOA
Responsiveness: Floor or ceiling effect <15%
Moderate (– –) Level of evidence rating II: Evidence obtained from a lesser quality (<50% critical
appraisal score) study of psychometric properties
Psychometric property rating (– –):
Internal consistency: Cronbach α < 0.7
Reliability: ICC or weighted κ < 0.70; Pearson’s r < 0.80
Measurement error: MIC ≤ SDC or MIC inside the LOA
Responsiveness: Floor or ceiling effect ≥15%
Moderate (?) Level of evidence rating II: Evidence obtained from a lesser quality (<50% critical
appraisal score) study of psychometric properties
Psychometric property rating (?):
Internal consistency: Cronbach α not determined
Reliability: Neither ICC or weighted κ, nor Pearson’s r determined
Measurement error: MIC not defined
Abbreviations: COSMIN, Consensus-based Standards for the Selection of Health Measurement Instruments; ICC, intraclass correlation coefficient; LOA, limits of
agreement; MIC, minimal important change; SDC, smallest detectable change.
a
From Terwee.8

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 189

JNPT-D-17-00190.indd 189 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018

TABLE 6. Process Used to Make Recommendations

STEP DESCRIPTION
1. Score articles Review and score methodological quality
for the study of psychometric properties
(internal consistency, reliability, mea-
surement error, and responsiveness)
2. Score strength of psychometric Review statistical results from articles,
properties score the psychometric property while
considering the article level of evidence
3. Combine results by OM Compile data by OM to view amount
and quality of literature, and strength of
psychometric property
4. Select OMs for consideration of core Compare the amount and strength of lit-
set erature available for each OM. If an OM
met the criteria listed, it was compared
with other OMs in the same construct
area.
Abbreviation: OM, outcome measure.
CRITERIA
Quality of each psychometric property
scored
Article assigned score of the lowest
scoring section
Level I if ≥50% criteria met
Level II if <50% criteria met
Statistical strength criteria listed in
Table 5.
Considered data for each OM for level
of evidence, strength of psychometric,
condition, and category (acute, chronic
progressive, chronic stable)
Prioritized OMs that met the following
criteria:
Level I evidence in ≥2 populations and
3 categories (acute, chronic stable, and
chronic progressive)
AND
Internal consistency and/or reliability
(strong +++) in 2 populations and
3 categories
AND
Standard error of measurement and/or
minimum detectable change data (strong
+++)/ (strong ?) in 2 populations and
3 categories
In cases in which a measurement con-
struct did not have an OM with this level
of evidence, we considered OMs that met
the following criteria:
Level I evidence in ≥2 populations and
3 categories (acute, chronic stable, and
chronic progressive)
AND
Internal consistency and/or reliability
(strong +++) in 2 populations and
2 categories
AND
Standard error of measurement and/or
minimum detectable change data
(strong +++)/(strong ?) in 2 popula-
tions and 2 categories

(n = 8). The aggregate score was 88%. Feedback from
the reviewers on the AGREE II and GLIA reviews was
integrated in the final CPG. It is anticipated that a fur-
ther review would result in a comparable/higher score.
3. A revised draft of the CPG was posted for public com-
ment on the ANPT, APTA, and Academy of Geriatric
Physical Therapy Web sites by the ANPT Director of
Practice. Notices of the public comment period were
distributed via email to CPG reviewers and others who
inquired about the CPG while it was in development. An
electronic newsletter and social media posting dissemi-
nated the public comment notice to ANPT members.
The posting was also made available on a web-based
190 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
listserv of PTs who treat individuals with neurologic
conditions. Listserv subscribers included members and
nonmembers of the ANPT. During the public comment
period, reviewers identified the following strengths of
the CPG: usefulness, value, clarity, comprehensiveness
of the literature review, and format. There were some
comments for improvement that the GDG determined
were beyond the scope of the CPG. Numerous sugges-
tions for dissemination were forwarded to the CPG KT
Committee.
4. The fourth review was completed by 2 Journal of
Neurologic Physical Therapy peer reviewers prior to
publication.

JNPT-D-17-00190.indd 190 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
Document Structure
The action statements are organized under the following
headings: the core set of OMs, discussing results of OMs,
and shared decision-making. After the action statement pro-
files, a section that describes implementation recommenda-
tions for all action statements is included. Lastly, acknowl-
edgments and references are provided.
THE CORE SET OF OUTCOME MEASURES FOR
NEUROLOGIC PHYSICAL THERAPY
A. Action Statement 1: STATIC AND DYNAMIC SIT-
TING AND STANDING BALANCE ASSESSMENT. Cli-
nicians should use the BBS for adults with neurologic condi-
tions who have goals to improve static and dynamic sitting
and standing balance and have the capacity to change in this
area. The BBS should be administered under the same test
conditions using the protocol recommended by the CPG KT
Committee at admission, and discharge, and when feasible,
between these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
Aggregate Evidence Quality and Strength: Level I;
strong. Based on 16 level I studies (see Supplemen-
tal Digital Content 7, Appendix 5, available at: http://
links.lww.com/JNPT/A220).
Benefits:
• The BBS demonstrates excellent internal consistency
and reliability, and data exist to assist in interpreta-
tion and measuring changes, in individuals with acute,
chronic progressive, and chronic stable neurologic
conditions. Floor and ceiling effects and information
to assist in OM result interpretation, such as MDC and
MCID, are available for individuals with acute, chronic
stable, and chronic progressive neurologic conditions.
• The BBS has high clinical feasibility, as it requires
minimal equipment, is free, and requires less than
20 minutes to administer.
• Ninety-seven percent of PTs surveyed reported that a
balance assessment is an essential component for the
core set.
• Initial costs of purchasing equipment (eg, stopwatches
and measuring device) are minimal and the required
equipment is commonly available in clinical set-
tings. The time cost to administer the test is less than
20 minutes.
Risk, Harm, and Cost:
• No adverse events were documented in research studies.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: The GDG emphasizes the impor-
tance of using standardized administration and scoring
procedures for measuring patients in the clinic. While
there is not a universally accepted protocol for the
BBS, we recommend that each clinical site adopt the
testing protocol developed by the CPG KT Committee
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 191
JNPT-D-17-00190.indd 191
(http://www.neuropt.org/professional-resources/anpt-
clinical-practice-guidelines/core-outcome-measures-
cpg). We recommend review of the standardized proce-
dures and, on an annual basis, establishing consistency
within and among raters using the BBS.
Intentional Vagueness: The BBS has demonstrated a
ceiling effect in individuals with acute,47-50 chronic sta-
ble,50,51 and chronic progressive conditions.52 The BBS
only includes one item that assesses sitting balance.
Therefore, if a patient has a primary goal to improve
sitting balance, the BBS should be administered in ad-
dition to a sitting balance measure.
Role of Patient Preferences:
• Sixty-eight percent of consumers surveyed reported that
balance was a common reason for seeking a PT referral.
• Clinicians should consider the degree to which im-
provements in balance are achievable and important to
each patient.
Exclusions:
• For patients who do not have explicit goals to improve
static and dynamic sitting and standing balance, the cli-
nician should document that the BBS was not adminis-
tered and provide a rationale (eg, not applicable due to
the patient’s current and expected functional capability
or not applicable due to a lack of related patient goals).
• Patients who have a high level of balance ability (eg,
able to walk without an assistive device at a gait speed
>1.0 m/s) may experience a ceiling effect on the BBS.
Quality Improvement:
• Organizations may use BBS results to assess balance
outcomes of individuals and groups with neurologic
conditions receiving rehabilitation.
• The physical therapy profession may use BBS scores to
describe the effectiveness of physical therapy services
for adults with neurologic conditions.
Implementation and Audit:
• The measurement error of the BBS may vary through-
out the scale. It may be more difficult to achieve high
reliability on individuals who score between 20 and
44.53,54 Measurement error has not been established for
individuals with an average score of less than 20, thus
it is unknown.54 Additional efforts may be needed to
standardize and improve reliability of BBS adminis-
tration in clinical practice for patients who score less
than 44.
• The BBS has demonstrated a ceiling effect in individu-
als with acute,47-50 chronic stable,50,51 and chronic pro-
gressive conditions.52 In patients who perform well on
the BBS, and score near the top of the scale, it may not
be necessary to readminister the test.
• Clinics and organizations should establish administra-
tion consistency within and among clinicians prior to
using the BBS, and this should be repeated annually.
Supporting Evidence and Clinical Interpretation
(Table 7)
Administration and Conditions: The BBS is a 14-item
clinician-rated scale that assesses sitting and standing, static
and dynamic balance.55 Considered one of the most com-
monly used measures in adult neurologic rehabilitation,56 the
09/06/18 2:22 PM
 TABLE 7. Evidence Table, Berg Balance Scale

JNPT-D-17-00190.indd 192
AUTHOR PRIMARY POPULATION LEVEL OF INTERNAL RELIABILITY STANDARD FLOOR CEILING EFFECTS
AND IMPAIRMENT LEVEL EVIDENCE CONSISTENCY (TYPE, RESULTS) ERROR; MDCs AND EFFECTS
(IF AVAILABLE) MCIDs
Berg Balance Scale, acute samples
Chinsongkram Stroke I NT NT NT 0% 4.3%
et al60
Gustavsen et al47 Stroke; subacute I NT NT NT NT 36% (admission)
rehabilitation
Lemay and SCI; AIS D; 15 paraplegia, I NT NT NT NT 37.5%
Nadeau48 17 tetraplegia
Mao et al49 Stroke I Cronbach α = Interrater NT 14 d 35%; 14 d = 4.9%;
0.92-0.98 ICC = 0.95 (total score); 30 d = 17.3%; 30 d = 11.8%;
weighted k = 0.92 90 d = 6.5%; 90 d = 21.5%;
(individual items) 180 d = 5% 180 d = 28.8%
Pickenbrock Stroke; acute care facility I NT Interrater: NT NT NT
et al57 Mean difference between
raters 0.13; LOA < ±1
point (−0.25, 0.51)
Salter et al59 Stroke; inpatient I NT NT NT 0% 0%
rehabilitation
Stevenson58 Stroke I NT Test-retest MDC 90% = 6; MDC NT NT
ICC = 0.92 95% = 7; SEM = 2.49
Berg Balance Scale, chronic stable samples
63
Hiengkaew et al Stroke; outpatient clinic I NT Test-retest SEM = 1.68 NT NT
ICC = 0.95 MDC = 4.66
Liaw et al64 Stroke I NT Interrater SEM = 2.4; NT NT
ICC = 0.98 MDC = 6.7
Tsang et al51 Stroke I NT NT NT 0% 32.10%
65
Wirz et al SCI I NT Interrater NT NT NT
AIS 4.8% A, 4.8% B, 83.3% ICC = 0.953
C, 7.1% D
(continues )

192 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT • Volume 42, July 2018

09/06/18 2:22 PM
 TABLE 7. Evidence Table, Berg Balance Scale (Continued )

JNPT-D-17-00190.indd 193
AUTHOR PRIMARY POPULATION LEVEL OF INTERNAL RELIABILITY STANDARD FLOOR CEILING EFFECTS
AND IMPAIRMENT LEVEL EVIDENCE CONSISTENCY (TYPE, RESULTS) ERROR; MDCs AND EFFECTS
(IF AVAILABLE) MCIDs
Berg Balance Scale, chronic progressive samples
62
Leddy et al PD; UPDRS/MDS mean I NT Interrater NT NT NT
72.6 (25-135); mean Hoehn
JNPT • Volume 42, July 2018

ICC = 0.95; test-retest

and Yahr 2.45 (4-66)
ICC = 0.79
(student PT), 0.80 (PT)
Paltamaa et al66 MS NA NT NT MIC-deterioration NT NT
EDSS median 2.0 (0-6.5) (clinician anchor)
=−0.60; MIC-
deterioration
(patient anchor)
=−1.41
Quinn et al11 HD I NT Test-retest MDC premanifest NT NT
(various stages) ICC = 0.86-0.97 HD = 1;
manifest HD = 5,
early-stage HD = 4,
middle-stage HD = 5,
late-stage HD = 5
Schlenstedt et al52 n = 85; PD; Hoehn and I NT Test-retest = 0.95 NT 0% 17.6%
Yahr mean 2.4; UPDRS
mean 40.1; 33% female,
67% male; mean age 67.2
(40-82)
Steffen and Seney10 PD; Hoehn and Yahr 1-4 I Cronbach Test-retest MDC = 5 NT NT
(median 2) α = 0.86-0.87 ICC = 0.94
Berg Balance Scale, acute and chronic stable mixed samples
Knorr et al50 Stroke, first data at average I NT NT NT 0% at baseline, 15% at baseline,
of 3.3 mo poststroke, second 0% at follow-up 21% at follow-up
data collection at average
8.2 mo poststroke
Abbreviations: AIS, American Spinal Injury Association Impairment Scale; d, day; EDSS, Expanded Disability Status Scale; HD, Huntington’s disease; ICC, intraclass correlation coefficient; LOA, limits of agreement; MCID,
minimal clinically important difference; MDC, minimal detectable change; MDS, Movement Disorder Society; MIC, minimal important change; MS, multiple sclerosis; NA, not applicable; NT, not tested; PD, Parkinson disease; PT,

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
physical therapist; SCI, spinal cord injury; SEM, standard error of measurement; UPDRS, Unified Parkinson’s Disease Rating Scale.
A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

193

09/06/18 2:22 PM

BBS has been well studied in research and widely used in
research and clinical practice. A standardized testing form
with administration instructions is available, and commonly
available equipment (chair, stopwatch, ruler, and step) is
used during testing. Each of the 14 items requires that the
patient perform a specific activity to challenge balance. The
patient’s ability to complete each item is rated on a 0- to
4-point scale, with 0 representing the inability to complete
the task and 4 reflecting independent item completion.
The total score is calculated by summing the scores of the
14 items, with the maximum score of 56 and the minimum
score of 0.56
Populations: The BBS can be applied across adult
neurologic conditions. This action statement is based on
16 level I studies that reported data in 7 acute samples (6
stroke)47,49,57-60 and 1 SCI,48 4 chronic progressive samples
(1 Huntington’s disease [HD]11 and 3 PD),10,52,62 4 chronic
stable samples (3 stroke51,63,64 and 1 SCI),65 and 1 study that
included a mixed acute and chronic stable sample (stroke).50
Psychometric Data: Reliability: Three level I studies
examined reliability in individuals with acute stroke and
demonstrated excellent interrater reliability. Mao et al49
assessed the total score (ICC = 0.95) and individual item
interrater reliability (weighted κ = 0.92). Using a Bland-
Altman plot, Pickenbrock et al57 demonstrated a mean differ-
ence among raters of 0.13. While this demonstrates high in-
terrater reliability, the article received a strong (?) reliability
rating because of the statistics used in the study.57 Excellent
test-retest reliability has been demonstrated in individuals
with stroke, with an ICC = 0.92.58
Three level I studies assessed reliability in chronic stable
conditions. Excellent interrater reliability (ICC = 0.953)
was demonstrated in individuals with chronic SCI.65 Test-re-
test reliability results were also excellent in individuals with
stroke, with ICCs of 0.9563 and 0.98.64
Four level I studies examined reliability in individu-
als with chronic progressive conditions. Quinn et al11 stud-
ied test-retest reliability of the BBS in individuals with HD,
which resulted in ICCs of 0.86 to 0.97 across 5 manifestations
of HD from premanifest to late-state HD.11 Three additional
studies of the BBS in PD suggest excellent interrater reliabil-
ity (ICCs of 0.9562 to 0.98),52 and good to excellent test-retest
reliability (ICCs of 0.94,10 0.95,52 and 0.79-0.80) in PD.62
Internal Consistency: Two level I studies demonstrat-
ed excellent internal consistency of the BBS in acute and
chronic progressive conditions, with a Cronbach α of 0.92
to 0.98 in individuals with acute stroke49 and 0.86 to 0.87 in
individuals with PD.10
SEM, MDC, MCID, Ceiling, and Floor Effects: Five
level I studies assessed SEM or MDC for the BBS; how-
ever, none simultaneously reported an MIC or MCID. Thus,
measurement error was rated as a strong (?) across the 5
studies. In participants with acute stroke, the SEM was 2.49
points,58 whereas in chronic stroke the SEM varied from
2.464 to 1.68 points.63 In individuals with HD (chronic pro-
gressive), the SEM was used to calculate the MDC, but was
not explicitly stated in the article.11 In participants with PD
(chronic progressive), Hoehn and Yahr classification of 1 to
4 (median = 2), the SEM was used to calculate an MDC, but
it was not explicitly reported.10
194 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 194
JNPT • Volume 42, July 2018
Five studies reported an MDC for the BBS. In partici-
pants with acute stroke, Stevenson58 reported an MDC95
of 7. In chronic stroke, the MDC95 varied from 4.6663 to
6.7 points.64 In chronic progressive conditions, the MDC95
varied based on the condition and severity. In participants
with HD, the MDC varied from 1 in individuals with pre-
manifest HD to 4 to 5 in individuals with other stages of
HD.11 Similarly, a study of individuals with PD demonstrat-
ed an MDC95 of 5.10 Only one study reviewed determined
an MIC for the BBS. In participants with MS, the MIC-
deterioration with clinician and patient anchors was −0.60
and −1.41, respectively.66
Six level I studies assessed the floor effects of the BBS.
No floor effects were identified in 2 studies of individuals
with acute stroke.59,60 In contrast, Mao et al49 identified the
presence of a floor effect that varied by time poststroke, de-
pending on the level of acuity as follows: 14 days = 35% (of
sample), 30 days = 17.3%, 90 days = 6.5%, and 180 days =
5%. Studies conducted on individuals with chronic stroke
and PD (mean Hoehn and Yahr = 2.4) indicated no floor
effect.51,52 Knorr et al50 did not find a floor effect at 3.3 and
8.2 months poststroke.
Eight level I studies assessed ceiling effects of the BBS.
In individuals with acute conditions, the presence of a ceiling
effect varied by study. Ceiling effects of 36%47 and 15%50 of
the sample were identified in subacute stroke, and 37.5%48 in
the SCI-ASIA Impairment Scale D. However, these results
conflict with other data that identified 0%59 to 4.3%60 ceiling
effect in a similar stroke population. A finding by Mao et al49
may provide a potential reason for these conflicts, as they
determined the ceiling effect varies by time poststroke, with
4.9% at 14 days, 11.8% at 30 days, 21.5% at 90 days, and
28.8% at 180 days. In individuals with chronic stroke, ceiling
effects of 21%50 and 32.1%51 have been identified. A ceiling
effect of 17.6% was also identified in individuals with PD.52
The strong recommendation for the BBS is based on lev-
el I evidence of internal consistency and/or reliability data,
availability of information to assist in assessing changes, and
floor and ceiling effect data across acute, chronic stable, and
chronic progressive conditions.
Related Outcome Measures: While several other bal-
ance OMs were assessed in this CPG, the only other OM that
assessed static and dynamic sitting balance in acute, chronic
stable, and chronic progressive conditions was the Trunk Im-
pairment Scale (TIS) (see Supplemental Digital Content 8,
Appendix 6, available at: http://links.lww.com/JNPT/A221).
This 10-item measure requires that a patient perform vari-
ous activities in a sitting position. Two publications, includ-
ing samples of acute and chronic brain injury67 and MS,68
demonstrated excellent reliability and established an SEM
in MS. Other psychometric properties were not established.
Because of the lack of psychometric evidence across catego-
ries, the TIS was not included in the core set.
Shorter BBS versions were considered (eg, BBS-3P,
BBS 9, and BBS-Short form). While decreasing BBS ad-
ministration time is desirable, these versions included dif-
ferent items and none had sufficient evidence to support use
across patient populations. The FGA and other OMs that
assess balance while walking were also reviewed, and have
been discussed later in this CPG.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
R. Research Recommendation 1: Researchers should fur-
ther examine the BBS to determine its psychometric prop-
erties in neurologic conditions other than stroke, SCI, PD,
HD, and MS. Properties such as SEMs, MDCs, and MCIDs/
MICs should be established for individuals with scores
throughout the range of the scale in all adult neurologic con-
ditions. Specific information regarding the functional levels
of individuals who may benefit from the BBS, and when to
start with or transition to another OM, is needed. Determina-
tion of optimal administration timing would assist clinicians
in administering the BBS within a reasonable time frame of
when “real change” would be expected. Development and
comprehensive testing of a BBS-Short form would decrease
administration burden.
R. Research Recommendation 2: Studies on OMs that pro-
vide a comprehensive assessment of sitting balance across
acute, chronic progressive, and chronic conditions are need-
ed. These should aim to determine the psychometric proper-
ties, including reliability, and to identify information to as-
sist in interpretation, such as MDCs and MIC/MCIDs.
B. Action Statement 2: WALKING BALANCE ASSESS-
MENT. Clinicians should use the Functional Gait Assess-
ment (FGA) for adults with neurologic conditions who have
goals to improve balance while walking and have the capacity
to change in this area. The FGA should be administered un-
der the same test conditions using the protocol recommended
by the CPG KT Committee at admission, and discharge, and
when feasible, between these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: moderate
Aggregate Evidence Quality and Strength: Level I;
moderate. Based on 5 level I and 1 level II studies (see
Supplemental Digital Content 7, Appendix 5, available
at: http://links.lww.com/JNPT/A220).
Benefits:
• The FGA demonstrates excellent internal consisten-
cy in individuals with acute and chronic stable neu-
rologic conditions and excellent reliability in indi-
viduals with acute, chronic progressive and chronic
stable neurologic conditions. Floor and ceiling ef-
fects, and data to assist in interpretation and measur-
ing change, such as MDC and MCID, are available
for individuals with acute and chronic stable neuro-
logic conditions.
• The FGA has high clinical feasibility, as it requires
minimal equipment, is available for free, and requires
less than 20 minutes to administer.
• Initial costs of purchasing equipment (eg, stopwatches
and measuring device) are minimal and the required
equipment is commonly available in clinical settings.
The time to administer the test is less than 20 minutes.
Risk, Harm, and Cost:
• No adverse events were documented in research studies.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 195
JNPT-D-17-00190.indd 195
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: The GDG emphasizes the impor-
tance of using standardized administration and scor-
ing procedures for measuring patients in the clinic.
While no single protocol has been validated for the
FGA, the GDG recommends that each facility adopt
the testing protocol developed by the KT committee
for this CPG (http://www.neuropt.org/professional-
resources/anpt-clinical-practice-guidelines/core-out
come-measures-cpg). We recommend review of the
standard procedures and, on an annual basis, estab-
lishing consistency within and among raters using the
FGA.
Intentional Vagueness: The FGA has not been as-
sessed for internal consistency, measures of change
(eg, MDC, SEM, and MCID), and floor or ceiling ef-
fects in individuals with chronic progressive neuro-
logic conditions.
Role of Patient Preferences:
• Sixty-eight percent of consumers surveyed reported
that balance was an important goal and a primary rea-
son for seeking physical therapy services.
• Clinicians should consider the degree to which im-
provements in balance are achievable and important to
individual patients when determining whether to ad-
minister the FGA.
Exclusions:
• Clinicians should use discretion when applying the
FGA with patients who do not have explicit goals to
improve balance while walking. Dynamic balance may
be required to perform other related tasks that are stat-
ed in the patient’s goals; in these cases, the FGA would
be appropriate to administer.
• The FGA should not be administered with patients
who do not have the capacity to walk. A score of 0
should be documented in these instances.
Quality Improvement:
• Organizations may use FGA data to assess balance
outcomes of individuals and groups with neurologic
conditions receiving rehabilitation.
• FGA scores may be used to describe the effectiveness
of physical therapy services for adults with neurologic
conditions.
Implementation and Audit:
• The FGA is intended to assess balance while walking,
and has demonstrated a ceiling effect in individuals
with balance and vestibular deficits seen in a tertiary
care center.69 If a patient demonstrates a high score
(near 30 out of 30), or is likely to do so, the clinician
may need to select a more challenging OM to assess
changes over time.
• If a patient is unable to ambulate, but has goals and ca-
pacity to improve balance, a baseline score of 0 should
be documented on the FGA.
• For patients who perform well on the FGA and score
near the top of the scale, it may not be necessary to
readminister the test.
• Clinics and organizations should establish administra-
tion consistency within and among clinicians prior to
using the FGA, and this should be repeated annually.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018

Supporting Evidence and Clinical Interpretation
(Table 8)
Administration and Conditions: The FGA is a 10-item
clinician-rated test that assesses balance while walking. The
items are rated on a 0- to 3-point scale, with 0 indicating
severe impairment and 3 indicating normal ambulation. To
score the FGA, the items are summed and a maximum total
score is 30. A testing form with administration instructions
is available,70 and commonly available equipment (obstacles,
stopwatch, and steps) is used during testing.
Populations: The majority of the studies reviewed for
this CPG examined acute and chronic stable conditions,
with only one level I study examining individuals with PD
(chronic progressive).62 Studies reviewed included level I
studies on individuals with acute and chronic stroke,71 acute
and chronic vestibular dysfunction,72 and a level II study on
acute vestibular dysfunction.69
Psychometric Data: Reliability: Interrater, intrarater
and test-retest reliability were assessed in articles reviewed
for this CPG. Leddy et al62 demonstrated excellent interrater
reliability (ICC = 0.93) in patients with PD with a mean
Hoehn and Yahr score of 2.45. A lower, but acceptable, inter-
rater reliability (ICC = 0.73) was demonstrated in a mixed
sample of individuals with acute or chronic vestibular dys-
function.72 Excellent intrarater reliability was found in acute
and chronic vestibular dysfunction (ICC = 0.94).72 Leddy
et al62 found that student PTs had a slightly lower, but still
excellent interrater reliability, with ICC = 0.80 as compared
with practicing PTs (ICC = 0.90). Excellent test-retest reli-
ability (ICC = 0.95) was also demonstrated in a mixed sam-
ple of individuals with acute or chronic stroke.71
Internal Consistency: Two studies (levels I and II) as-
sessed internal consistency of the FGA. Both studies dem-
onstrated excellent internal consistency, with a Cronbach α
of 0.86 in acute vestibular dysfunction69 and 0.88 in a mixed
acute and chronic vestibular population.70
SEM, MDC, MCID, Ceiling, and Floor Effects: Two
studies of levels I and II evidence assessed the MDC and/
or MDC% of the FGA, but neither study reported an MCID;
the methodological quality ratings were strong (?)71 and
moderate (?),69 respectively. In participants with mixed acute
and chronic stable conditions, Lin et al71 calculated an MDC
of 4.2. In individuals with acute vestibular dysfunction, the
SEM was utilized to determine the MDC of 6; however, the
SEM was not explicitly reported.69
Two studies (one level I and one level II) assessed the
FGA for ceiling and/or floor effects. In individuals with
acute vestibular dysfunction, the ceiling effect was 25%.69 A
much lower ceiling effect of 0% to 5.7% and a floor effect of
0% to 2% were found in a mixed sample of individuals with
acute or chronic stroke.71 It is important to note that these
studies were both completed in outpatient care settings. The
presence of floor or ceiling effects in an inpatient setting has
not been assessed.
The core set recommendation for the FGA was based
on levels I and II evidence in acute conditions, and level I

TABLE 8. Evidence Table, Functional Gait Assessment

PRIMARY
POPULATION STANDARD
AND IMPAIRMENT ERROR;
LEVEL (IF LEVEL OF INTERNAL RELIABILITY MDCs FLOOR CEILING
AUTHOR AVAILABLE) EVIDENCE CONSISTENCY (TYPE, RESULTS) AND MCIDs EFFECTS EFFECTS
Functional Gait Assessment, acute samples
Marchetti Vestibular II Cronbach NT MDC = 6 NT 25%
et al69 (tertiary care center) α = 0.86
Functional Gait Assessment, chronic progressive samples
Leddy et al 62
PD I NT Interrater NT NT NT
(mean Hoehn and ICC = 0.93
Yahr 2.45) Test-retest
ICC = 0.80
(student), 0.91
(PT)
Functional Gait Assessment, mixed acute and chronic stable samples
Lin et al 71
Stroke I NT Test-retest MDC = 4.2 0%-2% 0%-5.7%
(outpatient ICC = 0.95
MDC% = 14.1
rehabilitation)
Nilsagård Vestibular I Cronbach Intrarater NT NT NT
et al72 α = 0.88 ICC = 0.94
Interrater
ICC = 0.73
Abbreviations: ICC, intraclass correlation coefficient; MCID, minimal clinically important difference; MDC, minimal detectable change; NT, not tested; PD,
Parkinson disease; PT, physical therapist.

196 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 196 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
evidence in chronic stable and chronic progressive condi-
tions. Data to assist with measuring change are lacking in
chronic progressive conditions. Therefore, the FGA received
an aggregate recommendation rating of moderate.
Related Outcome Measures: Several OMs that assess
balance while walking were reviewed for this CPG, and 4 had
sufficient evidence to be considered for the core set. While
the FGA had the highest-quality evidence across patient cat-
egories, the Dynamic Gait Index (DGI), Mini-Balance Eval-
uation Systems Test (Mini-BESTest), and Timed Up and Go
(TUG) were also considered. The level of evidence for each
measure is available (see Supplemental Digital Content 7,
Appendix 5, available at: http://links.lww.com/JNPT/A220).
The DGI (see Supplemental Digital Content 9, Appendix 7,
available at: http://links.lww.com/JNPT/A222) met the criteria
for the core set, but there were conflicting results from reliabil-
ity studies. In a level I study with individuals with acute ves-
tibular deficits, interrater reliability of the DGI was a κ of 0.64,
with individual items ranging from 0.35 to 1.0,74 whereas stud-
ies on PD75 and stroke71 demonstrated test-retest ICCs of 0.8475
and 0.94.71 The FGA was developed as a modification of the
DGI; both OMs include the following items: gait level surfaces,
changes in gait speed, gait with horizontal head turns, gait with
vertical head turns, gait with pivot turn, step over obstacle, and
stairs. Unlike the DGI, the FGA includes gait with narrow base
of support, gait with eyes closed, and ambulating backward.
The DGI includes step around obstacles, not included in the
FGA. The FGA provides more specific operational definitions
for its items. For example, the DGI indicates that the patient
must have “good speed” to achieve a score of 3/3, but the FGA
indicates the item must be completed in less than 5.5 seconds.
A modified version of the DGI76 was also assessed in this CPG;
however, it did not have enough evidence to be considered for
the core set. In summary, the FGA was selected instead of the
DGI for inclusion in the core set for the following reasons: bet-
ter reliability across acute, chronic stable and chronic progres-
sive populations; inclusion of clinically relevant balance items
of gait with narrow base of support, gait with eyes closed, and
ambulating backward; and improved response categories to fa-
cilitate consistency in OM administration.
The Mini-BESTest (see Supplemental Digital Content
10, Appendix 8, available at: http://links.lww.com/JNPT/
A223) was considered for inclusion in the core set of OMs;
however, it did not meet the established criteria. Data existed
from 1 level I study in acute conditions,60 2 level I studies in
chronic progressive conditions,52,77 and 1 level I study in a
chronic stable condition.51 No data were available on internal
consistency, reliability, and measures of change (eg, MDC
and MCID) in participants with acute conditions. Reliability
was studied in chronic progressive conditions, but internal
consistency and measures of change (eg, MDC and MCID)
were not examined.
The TUG (see Supplemental Digital Content 11, Appen-
dix 9, available at: http://links.lww.com/JNPT/A224) was
considered for the core set, with a total of 9 level I stud-
ies meeting review requirements. Although the majority of
the evidence was from participants with chronic progres-
sive conditions (HD,11 MS,78 PD,10,75,79 and postpoliomyeli-
tis),80 the TUG showed excellent reliability. In participants
with stroke,50,63,81 3 articles described the reliability, MDC,
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 197
JNPT-D-17-00190.indd 197
or ceiling and floor effects of the TUG. In participants with
acute stroke,50 only floor and ceiling effects of the TUG were
established. Furthermore, the TUG includes a sit-to-stand
transfer, walking speed, and turning, all of which are rep-
resented in other core set measures. Given the lack of reli-
ability data in acute conditions and the overlap with other
core set measures, the TUG was not selected for the core set.
R. Research Recommendation 3: Specific information re-
garding the functional levels of individuals who may benefit
from the FGA and when to start with or transition to an-
other OM is needed. Determination of optimal administra-
tion timing would assist clinicians in administering the FGA
within a reasonable time frame of when real change can be
expected. Development and psychometric testing of a FGA
short-form would decrease administration burden.
R. Research Recommendation 4: Studies are needed to ex-
amine other OMs, such as the Mini-BESTest and the TUG,
in individuals with acute, chronic progressive, and chronic
stable neurologic conditions. While the FGA had enough
evidence to support its inclusion of the core set, more com-
prehensive measures of standing and walking balance should
be tested to ensure a complete comparison against the FGA.
Properties such as reliability, internal consistency, measure-
ment error, floor and ceiling effects, MDCs, and MIC/MC-
IDs should be established across neurologic conditions.
A. Action Statement 3: BALANCE CONFIDENCE AS-
SESSMENT. Clinicians should use the ABC Scale to assess
self-reported changes in balance confidence in adults with
neurologic conditions who have goals and the capacity to
change in this area. The ABC should be administered under
the same test conditions using the protocol recommended by
the CPG KT Committee at admission, and discharge, and
when feasible, between these periods for patients with:
• Acute conditions: Evidence quality: I; recommenda-
tion strength: strong
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
Aggregate Evidence Quality and Strength: Level
I; strong. Based on 3 level I studies (see Supplemen-
tal Digital Content 7, Appendix 5, available at: http://
links.lww.com/JNPT/A220).
Benefits:
• The ABC demonstrates excellent internal consistency
and has data to assist in measuring changes in individu-
als with acute, chronic progressive, and chronic stable
neurologic conditions. Reliability has been assessed in a
chronic progressive condition. Floor and ceiling effects,
and information to assist in test result interpretation (eg,
MDC), are available for individuals with acute, chronic
progressive, and chronic stable neurologic conditions.
• The ABC has high clinical feasibility, as it is a patient-
reported measure, requires only a writing utensil, is
free to administer, and requires minimal time (5-10
minutes82).
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018

• The time cost associated with this measure is minimal,
as patients may be able to independently complete the
ABC prior to their initial clinical visit.
Risk, Harm, and Cost:
• No adverse events or financial costs were documented
in research studies.
• There may be a potential burden to patients, as the
ABC is a patient-reported measure.
• The tool is available in English, Turkish, and Spanish,
so there is a risk of misinterpretation of items for those
who are not fluent in these languages.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments:
• The GDG emphasizes the importance of using stan-
dardized administration and scoring procedures for
measuring patients in the clinic. While no single pro-
tocol has been used for the ABC, we recommend that
each clinical site adopt the testing protocol developed
by the CPG KT Committee (http://www.neuropt.org/
professional-resources/anpt-clinical-practice-guide-
lines/core-outcome-measures-cpg). We recommend
review of the standard procedures and, on an annual
basis, establishing consistency within and among rat-
ers using the ABC.
• Standardization procedures should be reviewed on an
annual basis.
• Administration of both clinician-rated and patient-re-
ported measures may provide a more comprehensive
assessment of balance confidence than administering
only a clinician rated measure.15
Intentional Vagueness:
• The ABC asks individuals to rate confidence in balance
while doing several tasks at home and community. Indi-
viduals with a recently diagnosed neurologic condition
may not have experience with these specific tasks since
the onset of the condition. Clinicians should begin admin-
istering the ABC when it is appropriate for the patient.
• Individuals with lack of insight into impairments may
have difficulty accurately answering the ABC questions.
In these cases, clinicians should use their judgment to
determine appropriateness of administering this test.
• Patients with hand impairments may require assistance
with recording their responses to the ABC.
Role of Patient Preferences:
• Sixty-eight percent of consumers surveyed reported
that balance was a common reason for seeking a PT
referral.
• Clinicians should consider the degree to which im-
provements in balance are achievable and important to
their individual patients when determining whether to
administer the ABC.
Exclusions:
• Clinicians should use discretion when applying the
ABC with patients undergoing neurologic rehabilitation
who do not have goals to improve balance confidence.
Quality Improvement:
• Use of a single measure across clinical settings will
facilitate communication among clinicians and more
accurately reflect changes in a patient’s perceived bal-
ance confidence over time.
• Organizations may use data collected from the ABC
to assess changes in balance confidence in individuals
with neurologic conditions receiving rehabilitation.
• ABC scores may be used to describe the effectiveness of
physical therapy services for increasing balance confi-
dence perceptions in adults with neurologic conditions.
Implementation and Audit:
• While the ABC did not demonstrate a substantial ceil-
ing effect, if a patient demonstrates a score near 100%,
the clinician may stop using the OM for the purpose of
measuring change over time.
Supporting Evidence and Clinical Interpretation
(Table 9)
Administration and Conditions: The ABC is a patient-re-
ported OM that assesses a person’s perceived confidence in
performing functional activities without becoming unsteady
or falling. The stem, “How confident are you that you will

TABLE 9. Evidence Table, Activities-specific Balance Confidence

PRIMARY POPULATION RELIABILITY STANDARD
AND IMPAIRMENT LEVEL OF INTERNAL (TYPE, ERROR; MDCs FLOOR CEILING
AUTHOR LEVEL (IF AVAILABLE) EVIDENCE CONSISTENCY RESULTS) AND MCIDs EFFECTS EFFECTS
Activities-specific Balance Confidence, chronic progressive samples
Jonasson PD I Cronbach Test-retest SEM = 11% 0% 4.9%
et al83 % self-rated severity α = 0.98 ICC = 0.86
mild 24%, moderate
64%, severe 13%
Steffen and PD I Cronbach Test-retest MDC = 13; NT NT
Seney10 Hoehn and Yahr 1-4 α = 0.95-0.96 ICC = 0.94 SDD = 30.5%
(median 2)
Activities-specific Balance Confidence, acute and chronic stable mixed samples
Salbach Stroke I Cronbach NT SEM = 5.05 0% 0%
et al84 α = 0.94
Abbreviations: ICC, intraclass correlation coefficient; MCID, minimal clinically important difference; MDC, minimal detectable change; NT, not tested; PD,
Parkinson disease; PT, physical therapist; SEM, standard error of measurement; SDD, smallest detectable difference.

198 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 198 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
not lose your balance or become unsteady when you …?”
leads to 16 items. Each item is rated on a 0% to 100% scale,
and the total score is calculated by adding item scores and di-
viding by 16 (eg, the number of items). The resulting scores
range from 0% to 100% and reflect overall perceived confi-
dence. The ABC is a self (patient)-report measure; however,
questions can be read to an individual and the responses re-
corded. One study used a mailed version of the ABC, but
did not provide any details about instructions related to the
methods to complete the scale.83 Two studies were conducted
in a laboratory setting, but did not provide details about the
ABC test administration.10,84
Populations: The ABC has been tested in individuals
with acute, chronic progressive, and chronic stable condi-
tions. Two level I studies examined individuals with PD,10,83
and 1 level I study included a mixed sample of individuals
with acute and chronic stroke.84
Psychometric Data: Reliability: Test-retest reliability
was assessed in individuals with PD in 2 level I studies; both
demonstrated excellent reliability, with ICCs ranging from
0.8683 to 0.94.10 Reliability has not been assessed in acute or
chronic stable conditions.
Internal Consistency: In a sample with acute or chronic
stroke, Salbach et al84 demonstrated excellent internal con-
sistency (Cronbach α = 0.94). In 2 studies on individuals
with PD of various levels of impairment, the Cronbach α
ranged from 0.95 to .9680 to 0.98.83
SEM, MDC, MCID, Ceiling, and Floor Effects: SEM
was assessed in 3 level I studies, with results stated in 2
studies. In individuals with mixed acute and chronic stable
conditions, the SEM was 5.05.84 In PD, Steffen and Seney10
identified an SEM of 13% and the smallest detectable differ-
ence of 30.5%. Jonasson et al83 calculated an MDC of 11%.
While this MDC was relatively close to the SEMs reported
in individuals with PD, Steffen and Seney10 reported a sub-
stantially higher MDC of 30% in a similar sample. When
applying these data in clinical practice, the patient should be
similar to the sample studied.
Floor and ceiling effects of the ABC have been reported
in individuals with acute and chronic stroke and in PD. In a
mixed sample of individuals with acute or chronic stroke, no
floor or ceiling effects were identified (0%).84 In individu-
als with PD (self-rated severity, mild 25%, moderate 64%,
severe 13%), no floor effects and minimal ceiling effects
(4.9%) were identified.83
The strong recommendation for the ABC is based on lev-
el I evidence of internal consistency and/or reliability data,
and availability of data to assist in measuring change across
acute, chronic stable, and chronic progressive conditions.
Related Outcome Measures: No other patient-reported
OMs of balance had sufficient literature to be considered
for the core set. The Falls Efficacy Scale-International had
evidence to support its use in acute and chronic progressive
conditions (see Supplemental Digital Content 12, Appendix
10, available at: http://links.lww.com/JNPT/A225). In 3 sep-
arate level I studies, reliability, internal consistency, and data
to assist in measuring changes were established.83,85,86 Floor
and ceiling effects and MDCs have also been published. This
OM has also been translated and tested in many different
languages. Because of the lack of evidence to support the
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 199
JNPT-D-17-00190.indd 199
use of this measure with individuals who have chronic stable
conditions, it was not recommended for the core set.
R. Research Recommendation 5: Studies are needed to de-
termine the psychometric properties (eg, reliability) of the
ABC in acute, chronic progressive, and chronic stable neu-
rologic conditions. Furthermore, information to assist clini-
cians in interpreting the results of the ABC, such as MDCs
and MIC/MCIDs, should be established across neurologic
conditions. Specific information regarding the characteris-
tics of individuals who may benefit from the ABC is needed.
R. Research Recommendation 6: Studies are needed to
examine other OMs, such as the Falls Efficacy Scale Inter-
national, in individuals with acute, chronic progressive, and
chronic stable neurologic conditions. While evidence sup-
ports the inclusion of the ABC in the core set, other patient-
reported measures of balance should be studied to ensure
a comprehensive comparison to the ABC. Properties such
as reliability, internal consistency, measurement error, floor
and ceiling effects, MDCs, and MIC/MCIDs should be es-
tablished across neurologic conditions.
B. Action Statement 4: WALKING SPEED ASSESS-
MENT. Clinicians should use the 10 meter Walk Test
(10mWT) for adults with neurologic conditions who have
goals to improve walking speed and have the capacity to
change in this area. The 10mWT should be administered
(per the protocol by Steffen and Seney10 as adapted by the
CPG KT Committee) under the same test conditions at ad-
mission, discharge, and, when feasible, between these peri-
ods for patients with:
• Acute conditions: Evidence quality: V; recommenda-
tion strength: best practice
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: strong
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
Aggregate Evidence Quality and Strength: Level I;
strong. Based on 8 level I studies reporting reliability and/
or data to assist in measuring changes in acute, chronic
stable, and/or chronic progressive conditions, 2 level I
studies reporting ceiling and floor effect data in acute, and
1 study reporting only MIC data in a chronic progressive
condition (see Supplemental Digital Content 7, Appendix
5, available at: http://links.lww.com/JNPT/A220).
Benefits:
• The 10mWT demonstrates excellent reliability in in-
dividuals with chronic progressive and chronic stable
neurologic conditions. Data to assist in interpretation
and measuring change exists in acute, chronic progres-
sive, and chronic stable populations.
• Floor and ceiling effects have been assessed in indi-
viduals with acute neurologic conditions. Information
to assist in test result interpretation, such as MDC and
MIC, is available for individuals with acute, chronic
stable, and chronic progressive neurologic conditions.
• The 10mWT requires minimal equipment (eg, stop-
watch and equipment for measuring walkway distance),
09/06/18 2:22 PM

which is likely available in clinical settings or can be
purchased at a low cost. There is a minimal time cost
associated to administer the test (<5 minutes).
Risk, Harm, and Cost:
• No adverse events were documented in research stud-
ies.
• Administering the 10mWT has minimal risks, provid-
ed the patient’s vital signs are monitored and appropri-
ate guarding is used.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments:
• The GDG emphasizes the importance of using stan-
dardized administration and scoring procedures for
measuring patients in the clinic. While no single pro-
tocol has been used for the 10mWT, Quinn et al11 and
Steffen and Seney10 described standardized proce-
dures. The GDG recommends the protocol by Steffen
and Seney because both comfortable and fast speeds
were tested, providing an assessment of the patient’s
ability to alter gait speed. In addition, Steffen and
Seney used a shorter walkway (the 10-m as compared
with the 14m walkway used by Quinn et al), which may
be more feasible in smaller spaces. This protocol has
also been adapted by the ANPT CPG KT Committee
(http://www.neuropt.org/professional-resources/anpt-
clinical-practice-guidelines/core-outcome-measures-
cpg). We recommend review of the standard proce-
dures and, on an annual basis, establishing consistency
within and among raters using the 10mWT.
• Walking safety may be more of a priority in acute
and subacute rehabilitation to prepare for discharge,
whereas walking speed may be a higher priority there-
after.
• Community ambulation requires the ability to ambu-
late at various speeds. The 10mWT enables the assess-
ment of comfortable and fast walking; therefore, it is
a useful measure to determine a patient’s ability to re-
sume community ambulation.
Intentional Vagueness: It is possible that authors of
the studies reviewed used different administration pro-
cedures, resulting in some variability in the 10mWT
protocols used among studies.
Role of Patient Preferences: Eighty-eight percent of
consumers surveyed expressed that it was important to
improve walking and 83% reported that difficulty with
walking was a primary reason for seeking physical
therapy.
Exclusions: The 10mWT is not appropriate for pa-
tients who do not have the capacity to walk. The GDG
recommends that a score of 0 m/second be documented
for patients who are unable to walk at a given point in
time, but who have goals and the capacity to walk in
the future.
Quality Improvement:
• Use of a single measure across clinical settings will fa-
cilitate communication among clinicians and enable as-
sessment of changes in a patient’s gait speed over time.
• Identifying a patient’s capacity to return to specific ac-
tivities requiring various gait speeds may be enhanced
when using the 10mWT.
200 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 200
JNPT • Volume 42, July 2018
• Standardizing a gait speed measure for patients with
neurologic conditions within and across clinical set-
tings will enable comparative outcomes for quality
improvement initiatives. Because scores may differ
based on testing protocol, it may be difficult to com-
pare data collected in different facilities unless the pro-
tocol is also specified. Individual organizations should
use the CPG-recommended standardized protocol by
Steffen and Seney10 to assess aggregate data for their
patients. In cases when the protocol cannot be used,
the modifications to the OM administration should be
documented.
Implementation and Audit:
• The GDG recommends that clinicians use the protocol
by Steffen and Seney,10 which has been adapted by the
CPG KT Committee.
• For patients who are unable to walk at admission but
have goals and the capacity to improve in this area, a
score of 0 m/second should be documented to track pa-
tient change as ambulatory ability improves.
• The distance of the 10mWT is short and the use of as-
sistive devices is permitted, which facilitates its use
across functional levels and environments (eg, home).
The type of device must be documented.
• Clinics and organizations should establish administra-
tion consistency within and among clinicians prior to
using the 10mWT, and this should be repeated annually.
Supporting Evidence and Clinical Interpretation
(Table 10)
Administration and Conditions: The 10mWT involves
measuring the time it takes for a person to walk the distance,
with results typically reported in meters/second (m/s). The
patient’s ability to walk at both comfortable and fast speeds
can be measured, and assistive devices can be used. Quinn et
al11 and Steffen and Seney10 have described detailed admin-
istration procedures. Both used a walkway length of 10 m,
but varied in their measurement of the entire walkway11 ver-
sus the central 6 m.10 Quinn et al11 also measured the number
of steps taken during the test. Both Quinn et al11 and Stef-
fen and Seney10 administered 2 trials; Quinn et al11 reported
separate time data on each trial whereas Steffen and Seney10
averaged the time from the 2 trials.
The 10mWT protocol by Steffen and Seney10 is recom-
mended by the GDG. This protocol assesses the time to
the nearest 100th of a second to walk the central 6 m of a
10-m walkway at the patient’s comfortable and fast walk-
ing speeds. The time starts when any part of the foot crosses
the plane of the tapeline and ends when any part of the foot
crosses the plane at the 6-m mark. Two trials are adminis-
tered at the comfortable speed, with the instruction “walk at
your own comfortable speed and stop when you reach the far
line,” followed by 2 trials at the fast speed, with the instruc-
tion “walk as fast as you can safely walk.” The 2 trials, for
each speed, are averaged and the 2 gait speeds are document-
ed in meters/second. Use of an assistive device is permitted
and should be documented. CPG KT Committee adaptations
are located online at: http://www.neuropt.org/professional-
resources/anpt-clinical-practice-guidelines/core-outcome-
measures-cpg/core-measures.
09/06/18 2:22 PM
 TABLE 10. Evidence Table, 10 meter Walk Test
PRIMARY
POPULATION AND LEVEL

JNPT-D-17-00190.indd 201
IMPAIRMENT LEVEL OF EVI- INTERNAL RELIABILITY STANDARD ERROR; MDCS FLOOR CEILING
AUTHOR (IF AVAILABLE) DENCE CONSISTENCY (TYPE, RESULTS) AND MCIDs EFFECTS EFFECTS
10 meter Walk Test acute samples
Lemay and SCI; AID D I NA NT NT NT 0%
Nadeau48
Perera et al88 Stroke I NA NT “Substantial meaningful NT NT
JNPT • Volume 42, July 2018

change” (decline) = 0.01 m/s

(anchor-stairs) or 0.10 m/s
(anchor-walk block) (depending
on anchor); SEM = 0.04 m/s
Scrivener Stroke—assessed within I NA NT NT On admission 67%; NT
et al87 48 h on discharge 26%
10 meter Walk Test chronic stable samples
Hiengkaew et al63 Stroke I NA Test-retest MDC = 0.18 m/s NT NT
ICC = 0.96
Scivoletto SCI; mean time since onset I NA Intrarater ICC = 0.98-99; NT NT NT
et al89 24 mo; 20 nontraumatic; interrater ICC = 0.95-0.98
12 tetraplegia, 25 paraple-
gic; 35 AIS D, 2 AIC C
10 meter Walk Test chronic progressive samples
Nilsagård MS; EDSS 3-6 I NA Test-retest Smallest % difference NT NT
et al78 ICC = 0.97 change = −23/+30
Paltamaa MS; median EDSS 2.0 NA NA NT MIC self-paced-deterioration NT NT
et al66 (0-6.5); 88% relapsing- (MIC only) (patient anchor) = −0.14 m/s;
remitting MIC fast-paced deterioration
(clinician anchor) = −0.19
m/s; MIC fast-paced dete-
rioration (patient anchor) =
−0.11 m/s
Quinn et al11 HD from premanifest to I NA Test-retest MDC-pre-manifest HD = NT NT
late state ICC = 0.92-0.97 0.23 m/s; manifest HD = 0.34
m/s; early-stage HD = 0.20
m/s; middle-stage HD = 0.46
m/s; late-stage HD = 0.29 m/s

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
Steffen and PD; Hoehn and Yahr 1-4 I NA Test-retest MDC comfortable = NT NT
Seney10 (median 2) ICC = 0.96 (comfortable 0.18 m/s; fast = 0.25 m/s
speed) -0.97 (fast speed)
A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

201
(continues )

09/06/18 2:22 PM
 JNPT • Volume 42, July 2018

Populations: Ten level I studies on the 10mWT

Abbreviations: AIC, Akaike information criterion; AIS, American Spinal Injury Association Impairment Scale; BI, brain injury; EDSS, Expanded Disability Status Scale; HD, Huntington’s disease; ICC, intraclass correlation coefficient;
EFFECTS
CEILING
across all categories were reviewed: 3 acute (1 SCI48 and 2
stroke87,88), 4 chronic progressive (1 MS78, 1 HD11, 1 PD10,

NT

NT
and 1 postpolio80), 2 chronic stable (stroke63 and SCI89), and

MCID, minimal clinically important difference; MDC, minimal detectable change; MS, multiple sclerosis; NA, not applicable; NT, not tested; PD, Parkinson disease; SCI, spinal cord injury; SDC, smallest detectable change.
a mixed sample with acute stable, and chronic progressive
conditions.90 Meaningful change data have been reported in
acute (stroke)88 and chronic progressive (MS66) populations.
Reliability has not been determined in acute neurologic con-
ditions. Floor and ceiling effects have not been studied in
EFFECTS
FLOOR

individuals with chronic progressive and chronic stabile neu-

rologic conditions.
NT

NT
Psychometric Data: Reliability: Intrarater (ICC = 0.98-
0.99) and interrater (0.95-0.98) reliabilities were reported in
STANDARD ERROR; MDCS

one study in participants with SCI (chronic stable).89 Test-

SDC = 1.9 m/s (preferred);

retest reliability was established (ICC = 0.96) in patients

with stroke (chronic stable).63 Four studies examined test-
retest reliability in individuals with chronic progressive con-
ditions, including HD (ICCs ranged from 0.92 to 0.97 across
10 meter Walk Test mixed chronic stable and chronic progressive samples
1.7 m/s (fast)

manifestations of HD),11 MS (ICC = 0.97),78 PD (ICC =

AND MCIDs

0.96 and 0.97 for comfortable and fast speeds, respectively),10

and postpolio (ICC = 0.95 for both preferred and maximum
speeds).80 In a mixed population of chronic stable and chronic
NT

progressive participants, the test-retest reliability was ICC =

0.93.90 Collectively, these studies indicate excellent reliabil-
ICC = 0.95 (preferred and

ity of the 10mWT.

RELIABILITY (TYPE,

Only one study assessed interrater and intrarater reliabil-

ity; this emphasizes the importance of establishing the consis-
tency within and among clinicians within their own practice.89
The high test-retest reliability across individuals with various
ICC = 0.93
maximum)
RESULTS)
Test-retest

Test-retest

neurologic conditions suggests that the 10mWT can be ad-

ministered with consistent results across 2 time periods. No
article established the reliability of the 10mWT in individuals
with acute neurologic conditions. The reason for the lack of
focus on speed in the acute phase may be related to a higher
CONSISTENCY

priority and emphasis on walking recovery and patient safety.

INTERNAL

SEM, MDC, MCID, Ceiling, and Floor Effects: Data to

assist in interpretation and measuring changes were reported
in chronic stable (stroke; MDC = 0.18 m/s)63 and chronic
NA

NA

progressive conditions, including MS (smallest % differ-

ence change = −23/+30),78 HD (MDC = 0.20 m/s to 0.46
m/s across HD manifestations),11 PD (MDC = 0.18 m/s for
TABLE 10. Evidence Table, 10 meter Walk Test (Continued )

OF EVI-
DENCE
LEVEL

comfortable and 0.25 m/s for fast speeds),10 and postpolio

(smallest detectable change [SDC] = 1.9 m/s for preferred
I

and 1.7 m/s for fast speeds).80 A measurement error rating

myelopathy (3); and HD (3)

score of strong (?) was assigned to each study, due to the

duration of new symptoms

Various neurologic condi-

lack of MIC/MCID data. “Substantial meaningful change”

IMPAIRMENT LEVEL

tions; primarily BI (8);

stroke (21); tumor (3);

and SEM data were established in acute stroke (“substantial

Postpolio with mean
POPULATION AND

meaningful change” decline = 0.01-0.10) depending on the

(IF AVAILABLE)

anchor used.88 MIC was determined in MS78 (chronic pro-

gressive) (MIC = −0.11 to −0.19 m/s) depending on the
PRIMARY

anchor. Values for MDC vary across patient populations and

10.3 y

within a given neurologic condition as can be seen by review-

ing our evidence table. Similarly, MIC values vary depend-
ing on the selected anchor.66 Thus, clinicians should avoid
generalizing the results of one patient population to another
Stolwijk-Swuste

when considering MDC and MIC. These data can assist cli-
Rossier and

nicians when interpreting results of a patient’s 10mWT.

AUTHOR

Related Outcome Measures: The Rivermead Mobility

Wade90
et al80

Index (RMI) (see Supplemental Digital Content 13, Appen-

dix 11, available at: http://links.lww.com/JNPT/A226) is a
202 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 202 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
measure that examines balance, transfers, and gait. It in-
cludes 1 performance-based item and 14 self-report items.
Five level I studies on the RMI included 2 in acute stroke,
reporting on internal consistency (Cronbach α = 0.93)91 and
interrater reliability (ICC = 0.92).92 In acute stroke, there is
a floor effect (30%) at admission to inpatient rehab,91 but
not at 5 weeks. Hsueh et al92 reported a floor effect at 14
days (40.4%), but not at 30 and 90 days; no ceiling effect
was found. Test-retest reliability has been established in
chronic stable (stroke; ICC = 0.96),93 chronic progressive
(HD; ICC ranged from 0.81 to 0.98 across HD manifesta-
tions),11 and a mixed chronic stable and chronic progressive
group (ICC = 0.96).90 A smallest real difference of 2.2 was
reported in stroke (chronic stable)91 and chronic progressive
populations, with MDCs ranging from 1 to 5 across HD
manifestations.11 One level II study established an SEM of
0.49 in MS.94 Although RMI data are available across cat-
egories, the RMI is composed of 15 items, only 5 of which
pertain to gait (on level, unlevel, and stair surfaces). Thus,
the RMI is not solely a measure of gait. Because consumers
reported that gait was of importance, the GDG selected a
gait-specific measure for the core set. Hence, the RMI was
not included.
The Timed 25 Foot Walk (see Supplemental Digital Con-
tent 14, Appendix 12, available at: http://links.lww.com/JNPT/
A227) is a measure of gait speed (eg, the time to walk 25 ft).
Eight level I studies on persons with MS (chronic progressive)
establish its reliability in this population, with intrarater and
interrater ICC values of 0.98 and 0.99, respectively.95 Six stud-
ies96-101 established test-retest ICC values ranging from 0.9296
to 0.991.97 In addition, MIC values (ranging from −0.01 to
−3.55 seconds)102 have been reported, as have SEM, MDC,
and MDC% (= 1 second, 2.7 seconds, and 36%, respective-
ly).97 While the Timed 25 Foot Walk could have broad appli-
cability, there is less evidence overall to support its use across
populations as compared with the 10mWT.
The Walk-12 is a self-report walking measure that as-
sesses the impact of a person’s neurologic condition on walk-
ing capability. One level I study reported internal consisten-
cy (Cronbach α = 0.94), and floor (21.7% at admission and
0.9% at discharge) and ceiling effects (0.9% at admission
and 0% at discharge) in a mixed chronic stable and chronic
progressive sample.103 Further research would be beneficial,
as the Walk-12 would complement the performance-based
measures of gait included in the CPG.
R. Research Recommendation 7: Studies are needed to ex-
plore the reliability and clinically important change (eg, MCID)
of the 10mWT in individuals with acute neurologic conditions.
Clinically important change should also be determined in
chronic stable conditions. Studies to determine the presence of
floor and ceiling effects should be conducted in persons with
chronic progressive and chronic stable conditions.
R. Research Recommendation 8: Studies are needed to
examine the Walk-12 in individuals with acute, chronic pro-
gressive, and chronic stable neurologic conditions. Proper-
ties such as reliability, internal consistency, measurement
error, floor and ceiling effects, MDCs, and MIC/MCIDs
should be established across neurologic conditions.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 203
JNPT-D-17-00190.indd 203
B. Action Statement 5: WALKING DISTANCE AS-
SESSMENT. Clinicians should use the 6 Minute Walk Test
(6MWT) for adults with neurologic conditions who have
goals to improve walking distance and the capacity to change
in this area. The 6MWT should be administered (per the
Quinn et al11 protocol as adapted by the CPG KT Committee)
under the same test conditions at admission, and discharge,
and when feasible, between these periods for patients with:
• Acute conditions: Evidence quality: V; recommenda-
tion strength: best practice
• Chronic stable conditions: Evidence quality: I; recom-
mendation strength: moderate
• Chronic progressive conditions: Evidence quality: I;
recommendation strength: strong
Aggregate Evidence Quality and Strength: Level I;
moderate. Based on 5 level I studies, reporting both
reliability and/or data to assist in measuring changes
in chronic progressive conditions; 3 level I studies in
chronic stable populations that reported reliability, but
no data to assist in measuring change; and, in acute pop-
ulations, 1 level I study reporting “substantial meaning-
ful change” and SEM, but no studies that examined reli-
ability (see Supplemental Digital Content 7, Appendix
5, available at: http://links.lww.com/JNPT/A220).
Benefits:
• The 6MWT demonstrates excellent reliability in pa-
tients with chronic progressive and chronic stable neu-
rologic conditions.
• Data to assist in measuring change (eg, MIC, SEM,
and MDC) have been assessed in individuals with
chronic progressive neurologic conditions, and “sub-
stantial meaningful change” and SEM are available for
individuals with acute conditions.
• The 6MWT has high clinical feasibility: it requires
minimal equipment typically available in most settings
and can be used for patients who walk with assistive
devices. Only one trial is needed, limiting the time to
administer the 6MWT.104 Standardized procedures for
test administration exist, as discussed later.
• Initial costs of purchasing equipment (eg, stopwatches,
cones, and distance measuring device) are minimal
and equipment is likely available in most settings. The
time to instruct the patient and administer the test is
less than 10 minutes, which can be minimized if the lo-
cation and landmarks for conducting the test are stan-
dardized within each clinical setting.
Risk, Harm, and Cost:
• No adverse events were documented in research stud-
ies reviewed for this CPG.
• Administering the 6MWT has minimal risks, provided
the patient’s vital signs are monitored and appropriate
guarding is used.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments:
• The GDG emphasizes the importance of measurement
reliability. Various protocols have been used for the
6MWT. To standardize administration and scoring, the
GDG recommends the protocol described by Quinn
et al.11 This protocol has also been adapted by the
09/06/18 2:22 PM

ANPT CPG KT Committee (http://www.neuropt.org/
professional-resources/anpt-clinical-practice-guide-
lines/core-outcome-measures-cpg). We recommend
review of the standard procedures and, on an annual
basis, establishing consistency within and among rat-
ers using the 6MWT.
• Home and community ambulation requires the ability
to walk for lengthy periods and distances. The 6MWT
can help determine a patient’s ability to resume activi-
ties requiring home and community ambulation.
Intentional Vagueness: The GDG assigned an ag-
gregate quality rating of moderate to this action state-
ment because of the lack of data to assist in measur-
ing change (eg, MDC, SEM, and MCID) in acute and
chronic stable conditions, and the absence of reliability
data in acute populations.
Role of Patient Preferences: Eighty-eight percent
of consumers surveyed reported that it was important
to improve walking, and 83% reported that gait dif-
ficulties were a primary reason for seeking physical
therapy.
Exclusions:
• The 6MWT is not appropriate for patients who do not
have the capacity to walk. The GDG recommends that
a score of 0 m be documented for patients who are
unable to walk at a given point in time, but who have
goals and the capacity to walk.
• The 6MWT may have limited feasibility in certain set-
tings, such as a hospital room or home environment with
limited walkway space or fixed environmental barriers.
Thus, clinicians will need to determine the feasibility
and appropriateness of the 6MWT in specific situations.
If unable to administer due to limited feasibility, the
clinician should document “unable to administer” and
provide an explanation in the patient’s medical record.
Quality Improvement:
• Use of a single measure across clinical settings will
facilitate communication among clinicians and more
accurately reflect changes in a patient’s walking endur-
ance over time.
• A clinician’s ability to determine a patient’s capacity
to return to activities requiring ambulation over long
distance (eg, community settings) may be enhanced by
using the 6MWT.
• Standardizing a walking endurance OM for patients
with neurologic conditions within and across clinical
settings will enable comparative outcomes for qual-
ity improvement initiatives. Because scores may differ
based on pathway, it may be difficult to compare data
collected in different facilities.
Implementation and Audit:
• The GDG recommends that clinicians use the proto-
col described by Quinn et al11 and adapted by the CPG
KT Committee described later under Administration
and Conditions. The recommended walkway length of
12 m is recommended for use by the GDG as longer
walkways (eg, 30-m recommended by the American
Thoracic Society)105 are unlikely to be feasible in all
environments (eg, small clinics or a patient’s home).
A shorter walkway length may facilitate continued
204 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 204
JNPT • Volume 42, July 2018
administration of the 6MWT as a patient transitions
from one service to another (eg, inpatient rehabilita-
tion to home).
• Any deviation from the recommended protocol, in-
cluding use of encouragement and physical assistance,
should be documented.106
• For patients who are unable to walk at admission but
have goals and the capability to improve ambulatory
capability, a score of 0 m should be documented. This
will capture changes over time as the patient’s ambula-
tory capability improves.
• Only one trial of the 6MWT is necessary, as there is no
practice effect when administering 2 trials.104
• Clinics and organizations should establish administra-
tion consistency within and among clinicians prior to
using the 6MWT, and this should be repeated annually.
Supporting Evidence and Clinical Interpretation
(Table 11)
Administration and Conditions: The 6MWT measures the
distance an individual can walk in 6 minutes. A systematic
review of timed walking tests for persons with stroke identi-
fied 36 protocols for the 6MWT.106 Studies varied in regard
to walkway lengths (ranging from 10 to 85 m), shape (rect-
angular, oval, and circular), and tested speed (fast vs com-
fortable). The use of encouragement during the administra-
tion of the 6MWT varied and the impact is unclear.
Only Quinn et al11 described standardized procedures for
the 6MWT and the protocol recommended by the GDG. The
test is performed in a 12-m-long straight and unobstructed
walkway located in a quiet hallway or open area. A turn-
around point should have clear markings at each end, about
124-cm wide (eg, 2 cones width). The patient should be well
rested before this test. With the patient seated, the test is ex-
plained as specified by Quinn et al,11 contraindications are
checked, and resting heart rate is measured. The patient is
instructed to walk up and down the walkway continuously
without slowing, as able, for 6 minutes. Mobility aids may be
used and must be documented. The patient stands and resting
dyspnea (using the Borg scale) is measured. Encouragement
(eg, “you’re doing a good job and you have 5 minutes left)
is given after each minute of the test; no other communica-
tion should occur during the test. The patient may rest at any
time, but the stopwatch remains running and the number of
rests and the total rest time are recorded. Distance in meters,
walked at 1, 3, and 6 minutes, is recorded, as is the patient’s
heart rate before and after the test.
Various walkway lengths, ranging from 10 to 50 m, have
been used.89 Pathway distance has been shown to impact dis-
tance walked, with longer walkways resulting in greater dis-
tances walked,89 suggesting the importance of using a con-
sistent pathway within and across patients in a given clinical
setting.
Administration procedures for the 6MWT are clinical-
ly feasible with minimal low-cost equipment required (eg,
stopwatch and equipment for measuring walkway distance),
typically available in most clinical settings. Patients may use
assistive devices during the 6MWT, which enables use of
the measure across patients at various functional levels. Only
one trial is required, as there is no practice effect of 2 trials.104
09/06/18 2:22 PM
 TABLE 11. Evidence Table, 6-Minute Walk Test
PRIMARY
POPULATION AND

JNPT-D-17-00190.indd 205
IMPAIRMENT
LEVEL (IF LEVEL OF INTERNAL RELIABILITY FLOOR CEILING
AUTHOR AVAILABLE) EVIDENCE CONSISTENCY (TYPE, RESULTS) STANDARD ERROR; MDCs AND MCIDs EFFECTS EFFECTS
6-min Walk Test acute samples
88
Perera et al Stroke; subacute I NA NT “Substantial meaningful change” = 21 m NT NT
(anchor-stairs); = 54 m (anchor-walk block);
JNPT • Volume 42, July 2018

SEM = 22 m
6-min Walk Test chronic stable samples
104
Liu et al Stroke I NA Test-retest NT NT NT
ICC = 0.98
Ng and Hui-Chan81 Stroke I NA Test-retest NT NT NT
ICC = 0.98
Scivoletto et al89 SCI I NA Intrarater NT NT NT
ICC = 0.99;
Interrater
ICC = 0.99
6-min Walk Test chronic progressive samples
102
Baert et al MS; mild to severe I NA NT MIC improvement (patient anchor): 21.56 m NT NT
(whole group); 26.86 m (EDSS ≤4; 17.39 m
(EDSS 4.5-6.5); SRCindividual 67.22 m (whole
group); 42.86 m (EDSS ≤4; 75.42 m (EDSS
4.5-6.5).
MIC improvement (clinician anchor) = 9.06
m (whole group); 6.90 m (EDSS ≤ 4; 9.87 m
(EDSS 4.5-6.5); SRCindividual = 68.32 m; (whole
group); 56.53 m (EDSS ≤4; 73.98 m (EDSS
4.5-6.5)
Learmonth et al97 MS (79% relaps- I NA Test-retest SEM = 32 m; MDC = 88 m; MDC = 20% NT NT
ing remitting; 12% ICC = 0.959
secondary progres-
sive; 9% primary
progressive); mean
disease duration
11.8 (0.5-32) y;
mean EDSS 3.5

©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
(range 0-6.5)
  Motl et al98 MS; 82% RR I NA Test-retest NT NT NT
A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation

ICC = 0.959

205
(continues )

09/06/18 2:22 PM
 JNPT • Volume 42, July 2018

Populations: The 6MWT is appropriate for use in pa-

Abbreviations: EDSS, Expanded Disability Status Scale; HD, Huntington’s disease; ICC, intraclass correlation coefficient; MCID, minimal clinically important difference; MDC, minimal detectable change; MIC, minimal important
tients with any neurologic condition. Nine level I studies re-

EFFECTS
CEILING
ported data on the 6MWT, including 5 samples with chronic
progressive conditions (1 HD,11 1 PD,10 and 3 MS97,98,102),

NT

NT

NT
3 samples with chronic stable conditions (1 SCI89 and 2
stroke81,104), and 1 in acute populations.88 One study reported
“substantial meaningful change” and SEM in acute (stroke)
EFFECTS

populations;88 another reported MIC in chronic progressive

FLOOR

(MS)66 populations.
NT

NT

NT
Psychometric Data: Reliability: Intrarater and inter-
rater reliability (both ICCs = 0.99) were reported in par-

change; MS, multiple sclerosis; NA, not applicable; NT, not tested; PD, Parkinson disease; RR, risk ratio; SCI, spinal cord injury; SEM, standard error of measurement; SRC, smallest real change.
ticipants with SCI (chronic stable).89 Test-retest reliability
MDC-premanifest HD = 39.22 m; manifest
= −55.06 m; MIC-deterioration patient an-

has been established in chronic progressive conditions, in-

HD = 86.57 m; early-stage HD = 56.6 m;
middle-stage HD = 126.14 m; late-stage
STANDARD ERROR; MDCs AND MCIDs

cluding HD (ICCs ranged from 0.86 to 0.98 across mani-

festations of HD),11 PD (ICC = 0.96),10 and MS (ICC =
MIC-deterioration (clinician anchor)

0.959).97,98 Two studies established ICCs = 0.98 in partici-

pants with stroke (chronic stable).81,104 Collectively, these
studies indicate excellent reliability of the 6MWT, with the
great majority achieving the preferred reliability of 0.90 or
better.
chor) = −53.35 m

Only one study89 assessed both interrater and intrarater

reliability; this emphasizes the importance of establishing
HD = 70.65 m
MDC = 82 m

the administration consistency within and among clinicians

within their own practice. The high test-retest reliability
across participants with various neurologic conditions sug-
gests that the 6MWT can be administered with consistent
results across 2 time periods. The reliability of the 6MWT
in individuals with acute neurologic conditions was not as-
(TYPE, RESULTS)

ICC = 0.86-0.98

sessed in any study.

RELIABILITY

SEM, MDC, MCID, Ceiling, and Floor Effects: “Sub-

ICC = 0.96

stantial meaningful change” and SEM data have been report-

Test-retest

Test-retest

ed in participants with acute stroke.88 SEM and/or smallest

real change (SRC) data have been reported in individuals
NT

with chronic progressive conditions, including HD,11 PD,10

and MS.97,102 Paltamaa et al66 reported MIC data in persons
CONSISTENCY

with MS. Only one study102 was rated strong, as both SRC
INTERNAL

and MIC data were reported; the other studies10,11,97 were

rated strong (?) due to the lack of MIC/MCID data. Nev-
ertheless, data exist to assist clinicians when determining
NA

NA

NA

changes in a patient’s 6MWT score. Values for interpreting

TABLE 11. Evidence Table, 6-Minute Walk Test (Continued )

change (eg, MDC and MIC) can vary across patient popula-
tions, within a given neurologic condition, or depending on
EVIDENCE

(MIC only)
LEVEL OF

the anchor used, as is seen in Table 11. This suggests that cli-
nicians should avoid generalizing the results of one patient
NA

population to another population when considering data to

I

assess patient change.

Yahr 1-4 (median 2)

Data for use in assessing patient change have not been

POPULATION AND

relapsing-remitting
MS; median EDSS

HD from premani-

reported in individuals with chronic, stable neurologic condi-

2.0 (0-6.5); 88%

fest to late state

Steffen and Seney10 PD; Hoehn and

IMPAIRMENT

tions. No studies reported data for floor or ceiling effects in any

AVAILABLE)
LEVEL (IF

category, or reliability in acute populations, although “substan-

PRIMARY

tial meaningful change” and SEM data exist in persons with

acute stroke.88 Therefore, the 6MWT should be used with cau-
tion in individuals with chronic stable neurologic conditions.

Related Outcome Measures: The 2-Minute Walk Test

Paltamaa et al66

(2MWT) (see Supplemental Digital Content 15, Appendix

Quinn et al11

13, available at: http://links.lww.com/JNPT/A228) was re-

AUTHOR

viewed, as it is a clinically feasible measure of walking distance

and has applicability across patients with neurologic condi-
tions, especially those with fatigue (eg, persons with MS). Four
206 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA

JNPT-D-17-00190.indd 206 09/06/18 2:22 PM

 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
level I studies provide data on persons with stroke (chronic
stable), including test-retest reliability (ICC = 0.98) and
MDC (13.4 m).63 In chronic progressive samples, excellent
test-retest reliability (ICC = 0.95) exists in persons with
postpolio,80 and MIC (6.81 m) and SRC (26.64 m) have been
established in MS.102 Rossier and Wade90 established the test-
retest reliability (ICC = 0.97) in a mixed chronic stable and
chronic progressive sample.90 No studies reported data on
the 2MWT in acute populations. The 2MWT has compara-
ble test-retest reliability and the availability of data to inter-
pret change, but there was less evidence overall to support its
use across populations than the 6MWT.
R. Research Recommendation 9: Studies are needed to de-
termine the intrarater and interrater reliability, and clinically
important change (eg, MCID), of the 6MWT in individuals
with acute neurologic conditions. Data to assist in measuring
change (eg, MDC, SEM, and MCID) are needed in individu-
als with acute and chronic stable neurologic conditions.
P. Action Statement 6: TRANSFER ASSESSMENT. Clini-
cians should document the transfer ability of patients who have
goals to improve transfers and have the capacity to change.
Documentation should include the type of transfer, level of re-
quired assistance, equipment or context adaptations, and time
to complete. In patients who have goals and the capacity to im-
prove sit-to-stand transfers, the 5 Times Sit-to-Stand (5TSTS)
may be used. The 5TSTS and documentation of other transfers
may be administered under the same test conditions using the
protocol recommended by the CPG KT Committee at admis-
sion, discharge, and, when feasible, between these periods for
adult patients with neurologic conditions. (Evidence quality:
V; recommendation strength: best practice).
Aggregate Evidence Quality and Strength: Level V; best
practice. Based on the GDG clinical expertise, informed
by related evidence and the results of the clinician survey.
Benefits:
• Use of the 5TSTS will standardize one aspect of trans-
fer skill across patients and may provide information
about the methods a patient uses to complete the sit-
to-stand transfer.
• Initial costs of purchasing equipment (eg, stopwatches)
are minimal and the required equipment (eg, standard
chair) is commonly available in clinical settings. The
time to administer the test is less than 5 minutes.
Risk, Harm, and Cost:
• No adverse events relative to the use of the 5TSTS
were documented in studies reviewed for this CPG.
• Using an OM of transfers may extend the length of the
session.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments:
• 77% of clinicians surveyed indicated that transfers are
an important construct to measure.
• Transfers (ie, moving from one position to another,
such as sit to stand or wheelchair to mat) are a funda-
mental skill for daily life and an important component
of the physical therapy care provided to patients with
neurologic conditions.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 207
JNPT-D-17-00190.indd 207
• The use of OMs of transfers to assess and monitor
changes in individuals with neurologic conditions re-
flects best practice and is consistent with the APTA
Guide to PT Practice.
• The GDG emphasizes the importance of using stan-
dardized administration and scoring procedures for
measuring patients in the clinic. While there is not a
universally accepted protocol for the 5TSTS, we rec-
ommend that each clinical site adopt the testing proto-
col developed by the CPG KT Committee (http://www.
neuropt.org/professional-resources/anpt-clinical-
practice-guidelines/core-outcome-measures-cpg). We
recommend review of the standard procedures and, on
an annual basis, establishing consistency within and
among raters using the 5TSTS.
Intentional Vagueness:
• No single transfer OM had sufficient literature to support
a strong or moderate recommendation for the core set;
the 5TSTS received a best practice recommendation.
• Clinicians and organizations need to determine the fea-
sibility and utility of using an OM to measure transfers
in view of their patient population, facility-specific re-
quirements and resources, and payer requirements.
Role of Patient Preferences: Consumers of neurolog-
ic physical therapy surveyed indicated that the use of
standardized OMs is very important (58%) or impor-
tant (35%) to their care.
Exclusions: None.
Quality Improvement: Consistent use of a transfer
OM may enable clinicians and administrators to moni-
tor the patient’s change at an individual, unit, organiza-
tion, or system level.
Implementation and Audit:
• Procedures for administering the 5TSTS should be stan-
dardized for use by clinicians in the facility. The GDG
recommends the standard procedure developed by the
CPG KT Committee for administration of the 5TSTS.
The procedure is located on the ANPT Web site (http://
www.neuropt.org/professional-resources/anpt-clinical-
practice-guidelines/core-outcome-measures-cpg).
• Clinics and organizations should establish administra-
tion consistency within and among clinicians prior to
using the 5TSTS, and this should be repeated annually.
Supporting Evidence and Clinical Interpretation
(Table 12)
Administration and Conditions: The 5TSTS measures
the time it takes an individual to transfer from a seated to
a standing position and back to sitting 5 times. A patient is
instructed to sit with arms folded across their chest and with
back against the chair. Patients with stroke may have their
impaired arm at their side or in a sling. Chair heights of 43
to 45 cm have been reported in the literature. The patient is
instructed to stand up and return to sitting 5 times as quickly
as possible. Timing starts when the therapist says “go” and
ends when the patient’s body touches the chair following the
fifth repetition. Administration procedures for the 5TSTS
are clinically feasible with minimal low-cost equipment re-
quired (eg, stopwatch and chair), typically available in most
clinical settings.
09/06/18 2:22 PM

TABLE 12. Evidence Table, 5 Times Sit-to-Stand
PRIMARY
POPULATION
AND
IMPAIRMENT
LEVEL LEVEL OF INTERNAL
AUTHOR (IF AVAILABLE) EVIDENCE CONSISTENCY
5 Times Sit-to-Stand chronic progressive samples
Paul et al 79
Parkinson disease I NA
Abbreviations: ICC, intraclass correlation coefficient; MCID, minimal clinically important difference; MDC, minimal detectable change; NA, not applicable; NT, not
tested; SEM, standard error of measurement.
Populations: The 5TSTS has been studied in individuals
with chronic progressive conditions (PD).79
Psychometric Data: Reliability: One level I study reported
test-retest reliability (ICC = 0.91) in chronic progressive
conditions (PD).79 Reliability has not been assessed in indi-
viduals with acute or chronic stable populations; therefore,
the 5TSTS should be used with caution in these groups.
SEM, MDC, MCID, Ceiling, and Floor Effects: SEM was
reported to be 0.6s in individuals with chronic progressive
conditions (PD)79; however, data are lacking to assist with
measuring changes in acute or chronic stable neurologic
conditions. No studies reported data for floor or ceiling ef-
fects in any category. Therefore, the 5TSTS should be used
with caution in individuals with acute and chronic stable
neurologic conditions.
Related Outcome Measures: The Rivermead Mobility
Index-Modified (RMI-Mod) and the 30-second Chair Stand
Test (30SCST) were reviewed for this CPG. The 30SCST
was excluded because it did not have at least one article
on reliability and data to interpret changes in neurologic
populations.
Three articles supported the RMI-Mod,107-109 and these in-
cluded participants with acute stroke107,109 and a mixed popu-
lation of adults with acute and chronic progressive, but not
chronic stable neurologic conditions (see Supplemental Digi-
tal Content 16, Appendix 14, available at: http://links.lww.
com/JNPT/A229).108 All articles examining the RMI-Mod
were level I articles and reported internal consistency values
between 0.80 and 0.96 and reliability between 0.93 and 0.99.
Data to assist with measuring the change is lacking. While
the RMI-Mod met the initial criteria of at least 75% of the test
items matching the constructs of interest, only 50% of the test
items matched the construct of transfers. For these reasons,
the RMI-Mod was not recommended as a transfer OM.
R. Research Recommendation 10: Studies are needed that
explore the feasibility and psychometric properties of the
5TSTS to objectively describe the transfer abilities of adults
with neurologic conditions, especially those other than indi-
viduals with PD, across the continuum of care and spectrum
of acuity. Further study of the 30SCST is warranted, particu-
larly relative to reliability and data to interpret changes in
individuals with neurologic conditions.
208 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 208
JNPT • Volume 42, July 2018
STANDARD
ERROR;
RELIABILITY MDCs AND FLOOR CEILING
(TYPE, RESULTS) MCIDs EFFECTS EFFECTS
Test-retest SEM = 0.6 s NT NT
ICC = 0.91
P. Action Statement 7: DOCUMENTATION OF PATIENT
GOALS. Clinicians should document patient-stated goals and
monitor changes in individuals with neurologic conditions
using an OM such as the Goal Attainment Scale (GAS), re-
porting the task, the performance conditions, and the time to
complete or level of independence desired. Documentation of
patient goal measures should be administered under the same
test conditions at least 2 times, at admission and discharge,
and, when feasible, between these testing periods. (Evidence
quality: V; recommendation strength: best practice)
Aggregate Evidence Quality and Strength: Level
V; best practice. Based on the clinical expertise of the
GDG and informed by related evidence and the results
of the clinician survey.
Benefits:
• Seventy-nine percent of PTs surveyed for this CPG in-
dicated that patient-stated goals are an important con-
struct to measure.
• Using an OM of patient-stated goals will provide an
opportunity for patients and clinicians to share their
beliefs and values.
• An OM that assesses a patient’s goals may capture ac-
tivities or constructs not included in other OMs, but are
important to the patient.
• Use of an OM of patient-stated goals may assist clini-
cians in identifying and addressing discrepancies be-
tween perceived and actual performance.
Risk, Harm, and Cost: No adverse events were docu-
mented in studies reviewed for this CPG.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: The GDG believes that the use of
OMs that assess and monitor changes in patient-stated
goals in patients with neurologic conditions:
• Facilitates a patient-centered approach by integrating the
patient’s goals, priorities, and values into the plan of care.
• Will encourage patient engagement in the rehabilita-
tion process.
Intentional Vagueness: No patient-stated goal OM
had sufficient literature to support use across adults
with neurologic conditions.
Role of Patient Preferences: Using an OM of patient-
stated goals will allow patients to clearly state their
preferences for the focus of physical therapy.
Exclusions: In some situations, such as patients with im-
paired consciousness, cognition, and/or communication,
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
it may be challenging to ascertain the patient’s goals. A
caregiver may be able to provide a proxy response.110-112
Quality Improvement: Consistent use of a patient-
stated goal OM may enable clinicians to monitor the
patient’s perspective of change, and administrators to
monitor the degree to which patients perceive change
at an individual, unit, organization, or system level.
Implementation and Audit:
• Because a specific patient-stated goal OM was not rec-
ommended, the GDG recommends that each organiza-
tion select an appropriate OM to assess patient-stated
goals in regard to its patient population, facility-specific
requirements, and resources. The GAS, a measure that
was assessed during the CPG review process, has been
studied in other populations (eg, pediatric and geri-
atric) and may be applied to adults with neurologic
conditions.
• Administration procedures (eg, interview structure and
use of a proxy) for the organization’s chosen patient-
stated goal OM could be standardized for use in the
facility. Standardization regarding assessment and
documentation of this construct should include report-
ing the task, the performance conditions, and the time
to complete or level of independence desired. Patient
goals should be assessed at least 2 times, at admission
and discharge, and preferable in between these time pe-
riods under the same test conditions.
• When a discrepancy exists between perceived goals
and actual performance or capacity, clinicians should
provide education for the patient and caregiver and re-
view the goal expectations.
Supporting Evidence and Clinical Interpretation
General Overview: Patients’ and clinicians’ health beliefs
frequently lack agreement, affirming the need for discus-
sions about goals and shared decision-making with pa-
tients.113 Many OMs make the theoretical assumption that
all clients have similar goals leading to the challenge of cap-
turing the unique goals of individual clients.114 OMs have
been developed, which allow the clinician and the patient to
collaboratively and systematically establish individualized
goals and reach agreement on the scaling of these goals.
Patient-Stated Goals OM Considered in This CPG:
Three measures of patient-stated goals, the GAS, Canadian
Occupational Performance Measure, and Patient-Specific
Functional Scale, were reviewed for this CPG. The Canadian
Occupational Performance Measure was excluded because
it is proprietary and requires payment for use. The Patient-
Specific Functional Scale was excluded because it did not
have at least one citation each to support reliability and as-
sessment of change over time. Two citations for the GAS
were identified. One citation was excluded, as the subject
population included a mixed geriatric population, rather than
participants exclusively with neurologic conditions.115 A final
citation used the GAS with a neurologic population (brain
injury and stroke); the standardized response mean (2.2) was
reported, but data were lacking for reliability.116 One article
reported on participants with MS, but failed to meet the sam-
ple size required for inclusion in this CPG;117 others did not
focus on adults with neurologic conditions.118,119
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 209
JNPT-D-17-00190.indd 209
R. Research Recommendation 11: Studies should explore
the feasibility and psychometric properties, including reli-
ability and data to assist in interpreting change (eg, MDC
and MCID/MIC) of the GAS and other OMs that capture the
individual goals of adults with neurologic conditions across
the continuum of care and spectrum of acuity.
B. Action Statement 8: USE OF THE CORE SET OF
OUTCOME MEASURES. Clinicians should use and docu-
ment the OMs in the core set to assess change over time. The
core set includes the Berg Balance Scale (BBS), Functional
Gait Assessment (FGA), Activities-specific Balance Confi-
dence Scale (ABC), 10 meter Walk Test (10mWT), 6 Minute
Walk Test (6MWT), and 5 Times Sit-to-Stand (5TSTS) and
the recommended patient goal assessment for adults who are
undergoing neurologic physical therapy. The core set should
be administered with patients who have goals and the capac-
ity to improve transfers, balance, and/or gait. In cases when
a patient cannot complete one or more core set OMs (eg,
a patient who is unable to walk; thus, cannot complete the
10mWT or 6MWT), a score of 0 should be documented. The
patient goal assessment should be administered to all adults
undergoing neurologic physical therapy. The core set should
be administered under the same test conditions at least 2
times, at admission and discharge, and when feasible be-
tween these periods (Evidence quality: II; recommendation
strength: moderate).
Aggregate Evidence Quality and Strength: Level I;
moderate. Based on 41 level I studies for the 6 OMs
collectively (ABC, Berg, FGA, 6MWT, 10mWT, and
5TSTS) and 1 level II moderate study (FGA). Level I
studies provide moderate to strong evidence, supporting
the use of the BBS, FGA, ABC, 10mWT, and 6MWT
for patients with chronic stable and chronic progressive
conditions. Best practice recommendations support the
use of the 10mWT (2 level I studies) and the 6MWT (1
study reporting MIC) in patients with acute conditions.
A best practice recommendation was made for the
5TSTS based on 1 level I study in patients with chron-
ic progressive conditions. In addition, a best practice
recommendation was made that clinicians document
patient-stated goals and monitor changes using an OM.
In the survey to determine the scope of the core set, the
PTs indicated that balance (97%), gait (94%), patient-
stated goals (79%), and transfers (77%) were impor-
tant to address, and 94% of PTs indicated they were
willing or very willing to use a core set of OMs.
The aggregate strength of moderate was given because
the core set measures have not been studied collectively.
Benefits:
• Consumers of PT and clinicians were in agreement that
the constructs of gait, balance, transfers, and patient-
stated goals are important to assess. In addition, the
recovery of balance, gait, and transfers facilitate im-
proved independence for adults with neurologic con-
ditions. Therefore, a core set of OMs that captures
these constructs addresses the needs of patients and
practitioners. A comprehensive examination of all con-
structs, for which a patient has goals and the capacity
to improve in these goals, reflects best practice.
09/06/18 2:22 PM

• Use of the core set OMs for all patients with neurologic
conditions and in all settings will facilitate collection
of practice-based evidence to compare interventions
and programs.
• Use of the core set OMs across settings will facilitate
measurement of patient progress over time and across
the continuum of care. For example, as a patient moves
from acute care to inpatient rehabilitation to outpatient
services, or as a patient’s neurologic condition changes
over time due to recovery or its progressive nature, the
core set will reflect performance changes for the high-
est priority domains.
• Results of the core set of OMs can facilitate a compre-
hensive examination of balance, gait, and transfers to
assist with clinical decision-making, including the se-
lection of treatment interventions, modification of the
plan of care, and discharge decisions.
• Standardization of entry-level DPT and residency edu-
cation that includes training on the core set.
Risk, Harm, and Cost:
• No adverse events relative to the use of any of the mea-
sures in the core set were reported in studies reviewed
for this CPG.
• Organizational costs to administer the core set of OMs
may include the cost to alter the medical record to in-
clude data fields, time for staff training and test admin-
istration, and the cost of testing forms and equipment.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: The GDG believes that the use of a core
set of OMs will enhance patient outcomes because they
will standardize measures across settings. The core set will
contribute to the advancement of neurologic physical ther-
apy through the development of a learning health system
and the ability to do comparative effectiveness research.
Intentional Vagueness:
• The time frames for administration of the core set (eg,
admission, interim, and discharge) may vary depend-
ing on facility-specific requirements and length of stay.
• The GDG recommends administration of the core set
and sharing the measurement results with providers at
the next level of care. This is particularly important
when it is not feasible to administer the core set more
than once within a given setting.
• The measures in the core set were assessed primarily
in patients with central nervous system conditions.
Therefore, clinicians should use caution when apply-
ing these measures to patients with peripheral nervous
system conditions.
• Although evidence supports the use of each measure
in the core set, the use of the measures collectively has
not been studied.
Role of Patient Preferences:
• Consumers surveyed reported that OMs were very impor-
tant (60%) and somewhat important (36%) to their care.
• Selection of the appropriate OMs for an individual
patient should be based on a patient’s prognosis and
rehabilitation goals.
Exclusions:
• The OMs in the core set were assessed for reliability
and the ability to measure change over time. They were
210 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 210
JNPT • Volume 42, July 2018
not assessed for other purposes (eg, prediction or im-
pairment classification).
• In an acute care setting, in situations where a patient’s
length of stay is short, or when the patient is abruptly
discharged from a given setting, administration of the
core set at interim and discharge time frames may not
be feasible.
• If a patient does not have goals or a prognosis to im-
prove in specific construct areas, OMs should not be
collected in the specific goal areas. When an OM in the
core set cannot be administered (eg, due to a patient’s
current abilities or the patient does not have the capac-
ity to improve or goals in the area), the clinician should
document that the OM was not administered and pro-
vide a rationale (eg, not applicable due to the patient’s
current and expected functional capability or not ap-
plicable due to a lack of related patient goals).
Quality Improvement:
• The core set will facilitate monitoring of an indi-
vidual patient’s status across time and settings, and
the degree to which patients change in aggregate. The
data collected could be used to increase transparency
of outcomes; study clinician performance relative to
patient outcomes and internal and external bench-
marks; improve health care processes; and generate
new knowledge.
Implementation and Audit:
• The leadership of health care facilities and organiza-
tions should prioritize use of the core set and actively
support implementation.120
• Clinical facilities and organizations should standardize
the administration procedures (eg, equipment, instruc-
tions, and scoring) of the core set. Efforts should be
taken to standardize administration procedures and to
determine the consistency within and among clinicians
prior to using the core set OMs.
• Documentation of the core set should be standard-
ized to incorporate the following designated fields into
electronic health records: the BBS, FGA, Activities-
specific Balance Confidence Scale, 10mWT, 6MWT,
and 5TSTS. Fields to document the total score and in-
dividual items on the OM should be included. In addi-
tion, the following items may be documented when as-
sessing transfers: transfer ability of patients who have
goals to improve transfers and have the capacity to
change, inclusive of type of transfer, level of required
assistance, equipment or context adaptations, and time
to complete. When documenting patient goals, the
following items should be included: the task, the per-
formance conditions, and the time to complete and/or
level of independence desired.
• When a patient continues care at another level of ser-
vice, the core set results should be shared between fa-
cilities/organizations.
• Organizations should audit documentation regularly
to determine adherence to core set recommendations.
If adherence levels are not acceptable, audit and feed-
back, use of other knowledge translation interventions,
or quality improvement initiatives may improve routine
administration of the core set.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
Supporting Evidence and Clinical Interpretation
The concept of a core set of OMs for use in neurologic re-
habilitation has been discussed for over 10 years. The APTA
EDGE task forces made condition-specific recommenda-
tions for use of OMs in practice.121 The development, use,
and benefits of core sets, including those organized by con-
dition and construct, have been described.16 Measurement
core sets have been described/developed for clinical and
research use with individuals with stroke,106 MS,122 cerebral
palsy,123 vertigo and dizziness,124 and cerebellar ataxia.125
Other authors have advocated for OM core sets organized by
construct such as balance126 or gait.106 Most published core
sets have been developed by a consensus approach, such as
a Delphi process.123,126,127 While a modest amount has been
written in support of the development of OM core sets, the
literature on the demonstrated benefits of use in physical
therapy is extremely limited.128 Therefore, research is needed
on the impact of the core set on patients, organizations, and
the profession.
The use of OMs, including a core set of OMs, will cre-
ate the foundation for learning health care in adult neuro-
logic physical therapy, as recommended by the Institute of
Medicine.22 The OMs in the core set have value individually
as well as when used collectively in the care of adults with
neurologic conditions. All OMs, with the exception of the
5TSTS, have documented evidence of strong internal consis-
tency/reliability and data to assist in measuring change (eg,
SEM, MDC, and MCID) from multiple level I articles across
neurologic conditions and categories. Collectively, the core
set OMs capture the client’s status across constructs that
both PTs and consumers indicated to be important or related
to primary reasons for seeking physical therapy services.
Furthermore, the use of patient goal assessment will provide
standard reporting guidelines for patient goals. The core set
will facilitate a comprehensive examination of important
constructs in a patient’s care and support decision-making,
plan of care development, and achievement of outcomes col-
laboratively set by the patient and the clinician.
R. Research Recommendation 12: Studies are needed that
explore the impact of using the core set of OMs on rehabili-
tation outcomes, including factors related to implementation
(eg, time and cost). Studies should explore the impact of us-
ing the core set of OMs to support clinical decision-making
across neurologic conditions and categories. Future mea-
surement studies should be designed to meet the COSMIN
requirements for excellent methodology with regard to sam-
ple size, design, and rigor of statistical analysis of psycho-
metric properties.8,9,40,42
R. Research Recommendation 13: The CPG KT Committee
is developing standardized administration procedures for all 6
OMs in the core set. Studies are needed to determine the psy-
chometric properties of these protocols across acute, chronic
progressive, and chronic conditions in clinical practice.
P. Action Statement 9: DISCUSS OUTCOME MEA-
SURE RESULTS AND USE COLLABORATIVE/
SHARED DECISION-MAKING WITH PATIENTS.
Clinicians should discuss the purpose of OMs, results, and
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 211
JNPT-D-17-00190.indd 211
how these results influence treatment options with patients
undergoing neurologic physical therapy. Collaboratively, the
clinician and the patient should decide how these data should
inform the plan of care (Evidence quality: V; recommenda-
tion strength: best practice).
Aggregate Evidence Quality and Strength: Level V;
best practice. Based on the GDG clinical expertise and
informed by the consumer survey results and refer-
ences in other medical fields.
Benefits: Discussing the results of OMs with patients
may result in:
• Patients being more informed and engaged in rehabili-
tation.
• Better alignment of the plan of care with the patient’s
goals, preferences, and measurement results.
Risk, Harm, and Cost:
• No adverse events relative to the discussion of the re-
sults OMs were documented in the reviewed studies or
in a Cochrane review on the use of decision aids (eg,
interventions that support patients in shared decision-
making) to inform patients about care.129
• A discussion of the OM results may extend the length
of the session. Decision aid use to support shared
decision-making has been shown to mildly increase
(<3 minutes) the length of a patient’s consultation with
a health care provider.113
• When the results of OMs are not positive and/or pa-
tients have difficulty understanding the results, patients
may experience stress/discomfort and the discussions
may add time to the treatment session.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments:
• In a Cochrane review on decision aids (eg, interven-
tions that support patients in shared decision-making),
some benefits identified include increased participants’
knowledge, accuracy of risk perceptions, improved
alignment of values and care choices, and decreased
decisional conflict from feeling uninformed.129
• The GDG believes discussing the OM results and shar-
ing (eg, collaboratively) decision-making would ben-
efit patients undergoing neurologic physical therapy.
Intentional Vagueness: The time frames (eg, admis-
sion, interim, and discharge) for clinicians discuss-
ing the results of OMs and sharing decisions with
patients who have neurologic conditions may vary
depending on facility-specific requirements, patient
length of stay, etc.
Role of Patient Preferences: The majority of the con-
sumers surveyed reported that test results were very
important (60%) or important (35%) to them.
Exclusions: In some situations (eg, a patient with an im-
paired level of consciousness, cognition, or communica-
tion impairment), it may be challenging to discuss the
results of OMs with a patient. A caregiver may be able to
participate in these discussions and decisions as a proxy.
Quality Improvement:
• Mechanisms (eg, time and space for conversation)
should be developed to enable clinicians to share OM-
related information with patients and caregivers.
09/06/18 2:22 PM

• Sharing OM results and their impact on the plan of care
may help to:
• Engage and motivate a patient in his/her physical therapy.
• Facilitate shared decision-making regarding goals and
the plan of care.
Implementation and Audit:
• Organizations should develop procedures and docu-
mentation for the discussion of OM between the cli-
nician and the patient. Articles are available to guide
implementation of shared decision-making in clinical
practice, and may be applied to rehabilitation clinics.130
• Education and training on methods to discuss OM re-
sults and share decision-making may be required.
• A routine audit and feedback of documentation should
be performed to ensure adherence to the recommenda-
tions of sharing OM results and decision-making with
the patient.
Supporting Evidence and Clinical Interpretation
Shared decision-making is an approach in which patients and
clinicians make decisions collaboratively using the patient’s
health information, their values and preferences, and the best
available evidence. Patients are encouraged to consider ex-
amination and treatment options and communicate prefer-
ences. The clinician should collaborate with the patient to
assist in selecting the best plan of care. This approach dif-
fers from one in which a clinician makes decisions on behalf
of patients, and is intended to respect patient autonomy and
promote engagement.130,131 Sixty-percent of consumers sur-
veyed for this CPG reported that test results were “very im-
portant” to them. However, 13% did not recall whether their
PT conducted tests and 25% reported that tests were con-
ducted only at admission and discharge, but not in between
these 2 periods. It is possible that OMs were not consistently
used in the patients’ care, but these data may also indicate
that the consumers were not consistently informed about
the use of OMs. The majority of consumers reported that
the PT discussed the purpose (80%) and results (76%) of the
OMs used and that the PTs explained how the OM results
informed the plan of care (53%). Only 37% reported being
“very satisfied” with the information they received. The con-
sumers were not asked whether they shared decision-making
regarding the plan of care.
These data suggest that there is a need to improve the
provision of OM-related information to patients and to share
decision-making about the plan of care. Providing mean-
ingful information and sharing decisions throughout each
patient’s episode of care ensure that needs are met and the
patient understands the role of physical therapy in his/her
health care. This is particularly important, as patients’ and
clinicians’ health beliefs may lack agreement, confirming
the need for shared decision-making between clinicians and
patients.113
A recent Cochrane review129 concluded that decision aids,
which provide evidence-based information to inform patients
and support shared decision-making, can have a positive ef-
fect on communication between the provider and the patient.
Decision aids can inform patients and improve knowledge
(high-quality evidence), increase the patient’s involvement
in care (moderate-quality evidence), and integrate a patient’s
212 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 212
JNPT • Volume 42, July 2018
values with care decisions (low-quality evidence). Although
this review focused on decision aids for medical interven-
tions, it may have relevance for rehabilitation practice. Similar
outcomes (eg, enhanced patient involvement and knowledge)
may be achieved by providing patients with explicit informa-
tion about their OM results and collaboratively making deci-
sions about their care.
R. Research Recommendation 14: Research is needed on
the impact of discussing OM results and shared decision-
making with patients receiving neurologic physical therapy,
including the development and impact of OM-related infor-
mation (eg, OM-related decision aids) on the understand-
ing and involvement of a patient in his/her care and on the
achievement of patient goals. Furthermore, studies should
develop and test the use of decision aids that incorporate the
core set.
Limitations
There are several limitations to this CPG. As stated, this CPG
focused only on OMs to assess patient change over time.
Thus, other OM uses (eg, prediction) were not considered.
When critically appraising the articles, the focus was on the
strength of the psychometric properties of OMs, not avail-
able administration protocols. Our review of OMs reflected
the name of the measure (eg, BBS and 10mWT), not the
construct (ie, of balance or gait speed). Thus, it is possible
that some articles that may have been identified by construct,
rather than OM name, were not identified and reviewed. In
addition, it is possible that authors of the studies reviewed
used different administration procedures, resulting in some
variability in the protocols used among studies.
GUIDELINE IMPLEMENTATION
RECOMMENDATIONS
Overview: Implementation of the action statements con-
tained in this guideline is integral to the process of knowl-
edge translation (KT). KT has been defined as “the dy-
namic and iterative process that includes the synthesis,
dissemination, exchange and ethically sound application
of knowledge to improve health, provide more effective
health services and products, and strengthen the health care
system.”132 This complex process is impacted by many vari-
ables and is most effective when efforts are multifaceted
and sustained, and when they target barriers to the recom-
mended practice. Efforts at the individual, organizational,
and societal levels to support KT are critical to ensure
rapid and successful CPG implementation. Organizations
and clini­cians should assess their own barriers and facili-
tators to using the CPG action statements and develop a
KT plan that is tailored to overcome the identified barri-
ers. The GDG considered the literature and input from key
stakeholders related to barriers for the CPG (eg, time, cost,
and training needed to administer the core set; equipment)
when selecting OMs for the core set. The recommendations
given next may facilitate adoption and successful use of the
core set in practice. Use of KT frameworks can provide a
theoretical foundation for implementation, and may lead to
successful KT initiatives.133-137
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
Recommendations for Health Care Organizations and
Clinicians: The GDG recommends that organizations adopt
specific standardized practices related to use of this core
set of OMs and documentation of patient goals in clinical
practice.
• First, the core set should be used when a person under-
going neurologic physical therapy has goals and poten-
tial to improve balance, gait, or transfers.
• Patient goal documentation should adhere to the CPG
recommendations. The OMs should be administered to
a patient when evaluated in any setting. If a patient is
unable to perform a test, but will likely be able to per-
form some or all of the OM at some point in the future,
the patient should receive a zero on the initial test. This
provides an opportunity to capture data at a later point
in time, reflecting change that occurred.
• Follow-up measures should be administered at least
twice, with ideal administration time being the mid-
dle of treatment and at discharge. While it is recom-
mended to collect the core set at least once between
the admission and discharge assessment, the decision
to use the OMs for interim measurements is left to the
discretion of the clinician and the organization. Factors
such as length of stay, facility requirements, and re-
imbursement may impact the ability to administer the
core set at times other than admission and discharge.
However, an interim assessment will provide impor-
tant information about whether the patient’s status is
changing during the episode of care and may inform
intervention modifications. In cases when administra-
tion of the OMs multiple times is not feasible (eg, in
acute care), the GDG recommends that the clinician
administers the OM once and provide the measurement
results to the next level of care.
• In health systems with several levels of care, the core
set should be used throughout a patient’s episode of
care and measurement results should be provided to
the next level of care.
• Clinicians should utilize data from the core OM set
to describe progress to other health professionals (eg,
letters to insurance companies, physicians, and team
conference reporting).
• Documentation of the OMs should be standardized
within the facility based on the recommended methods
and incorporated into designated fields in the electron-
ic health record.
• Information, such as SEMs, MDCs, and MCIDs,
should be used to support decisions to alter the course
of treatment and discharge from care.
• Implementation of this core set may require time for
learning about the CPG and the recommended prac-
tices, comparing current practice with recommended
actions, and creating a plan for CPG implementation
within the organization.138,139 Specific protocols for
administering the core set have been recommended by
the GDG and CPG KT Committee (http://www.neu-
ropt.org/professional-resources/anpt-clinical-practice-
guidelines/core-outcome-measures-cpg).
Organizations and clinicians should determine interrater
and intrarater reliability of each core set measure annually
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 213
JNPT-D-17-00190.indd 213
and strive to achieve an agreement of more than 0.90 reli-
ability.140-142 OMs with a test-retest or interrater reliability of
less than 0.70 should not be used for individual patients.140,141
Establishing the reliability of clinicians in a clinical setting
should facilitate consistent measurement of a patient’s per-
formance (eg, when more than one clinician conducts a giv-
en test on an individual patient) or when measures are taken
over time (eg, at admission and discharge), and enhance a
clinician’s and organization’s confidence in the OM results.
In addition, increased reliability when using OMs may im-
prove the clinician’s ability to identify changes in function,
reduce measurement error, and improve the development
and modification of the plan of care. Training to ensure stan-
dardization of OM administration and skills assessment may
enhance reliability.
To promote adoption of the core set, organizations should
consider the use of KT interventions.143 A copy of the CPG
action statements should be kept in a location that is easy to
reference. Equipment and space to administer the core set
should be kept in an easily accessible location. Examination
forms should be adapted to include facility-specific informa-
tion, such as the location of equipment and local adaptation
to testing paths, and electronic and printed versions should
be made available. Initial training on administration of the
core set, how to use data to guide decision-making, and
methods to use core set data to collaboratively determine a
plan of care with patients (eg, shared decision-making) may
be required. This content should also be provided during new
hire orientation. Audit and feedback144 may facilitate adher-
ence to the recommendation that OM administration occurs
at admission and discharge, and preferably, at least once in
between. Audit criteria should include adherence to recom-
mended administration timing and documentation of OM in-
terpretation and shared decision-making. Tools to assist with
auditing will be developed by the CPG KT Committee, and
added to the ANPT Web site. Incorporating a requirement
to adhere to use of the core set into performance appraisals
will promote the use of the core set as a clinical and pro-
fessional expectation. Whenever possible, core set reminder
systems and decision-support tools should be integrated into
the electronic health system. These and other KT strategies
may be used to promote adoption throughout a health care
organization.
Integration With EDGE Recommendations: Six ANPT
EDGE task forces predated the development of this CPG. The
OM recommendations from those groups were focused on in-
dividuals with a specific neurologic condition (eg, stroke). It
is the intent of the GDG that, when caring for an individual
with a specific condition, clinicians integrate the core set with
the recommendations from the relevant EDGE task force.
The core set may be viewed as a “starting point” for measure
selection, with additional condition-specific measures as rec-
ommended by the EDGE task force used to provide insight
into issues specific to their patient’s health condition.
ANPT KT Taskforce Will Support CPG Implementation:
In collaboration with the GDG, the ANPT has developed a
KT task force made up of PTs practicing in different levels
of care: experts, early career PTs, supervisors, researchers,
patients, and educators. Their role is to support clinicians
and organizations in the dissemination and implementation
09/06/18 2:22 PM

of CPGs. The primary objective of the core set KT task force
is to develop implementation packages that will include KT
processes, products, and tools for organizations, clinicians,
and educators to use to implement the core set.
The GDG and the Practice Committee of the ANPT joint-
ly developed and disseminated the previous objectives with
an invitation to apply for membership on the task force. In-
terested stakeholders were asked to submit a statement of in-
terest and a curriculum vita. The ANPT Director of Practice,
214 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 214
JNPT • Volume 42, July 2018
Practice Committee Chair, and GDG reviewed applications
and selected members. Two task force cochairs and 7 mem-
bers agreed to participate.
The process of collaboration between the task force and
the GDG has begun and is anticipated to continue through
2019. As this process evolves, the KT task force, in conjunc-
tion with the GDG and the leadership of the ANPT, will fi-
nalize plans and develop multiple and diverse implementa-
tion recommendations and strategies.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
SUMMARY OF RESEARCH RECOMMENDATIONS
R. Research Recommendation 1: Researchers should fur-
ther examine the BBS, to determine its psychometric proper-
ties in neurologic conditions other than stroke, SCI, PD, HD,
and MS. Properties such as SEMs, MDCs, and MCID/MICs
should be established for individuals with scores through-
out the range of the scale in all adult neurologic conditions.
Specific information regarding the functional levels of in-
dividuals who may benefit from the BBS, and when to start
with or transition to another OM, is needed. Determination
of optimal administration timing would assist clinicians in
administering the BBS within a reasonable time frame when
“real change” would be expected. Development and compre-
hensive testing of a BBS short-form would decrease admin-
istration burden.
R. Research Recommendation 2: Studies on OMs that pro-
vide a comprehensive assessment of sitting balance across
acute, chronic progressive, and chronic conditions are need-
ed. These should aim to determine the psychometric proper-
ties, including reliability, and to identify information to as-
sist in interpretation, such as MDCs and MIC/MCIDs.
R. Research Recommendation 3: Specific information re-
garding the functional levels of individuals who may benefit
from the FGA and when to start with or transition to another
OM is needed. Determination of optimal administration tim-
ing would assist clinicians in administering the FGA within
a reasonable time frame when real change can be expected.
Development and psychometric testing of an FGA short-
form would decrease administration burden.
R. Research Recommendation 4: Studies are needed to ex-
amine other OMs, such as the Mini-BESTest and the TUG,
in individuals with acute, chronic progressive, and chronic
stable neurologic conditions. While the FGA had enough
evidence to support its inclusion of the core set, more com-
prehensive measures of standing and walking balance should
be tested to ensure a complete comparison against the FGA.
Properties such as reliability, internal consistency, measure-
ment error, floor and ceiling effects, MDCs, and MIC/MCIDs
should be established across neurologic conditions.
R. Research Recommendation 5: Studies are needed to de-
termine the psychometric properties (eg, reliability) of the
ABC in acute, chronic progressive, and chronic stable neu-
rologic conditions. Furthermore, information to assist clini-
cians in interpreting the results of the ABC, such as MDCs
and MIC/MCIDs, should be established across neurologic
conditions. Specific information regarding the characteris-
tics of individuals who may benefit from the ABC is needed.
R. Research Recommendation 6: Studies are needed to
examine other OMs, such as the Falls Efficacy Scale In-
ternational, in individuals with acute, chronic progressive,
and chronic stable neurologic conditions. While evidence
supports the inclusion of the ABC in the core set, other
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 215
JNPT-D-17-00190.indd 215
patient-reported measures of balance should be studied to
ensure a comprehensive comparison to the ABC. Properties
such as reliability, internal consistency, measurement error,
floor and ceiling effects, MDCs, and MIC/MCIDs should be
established across neurologic conditions.
R. Research Recommendation 7: Studies are needed to
explore the reliability and clinically important change (eg,
MCID) of the 10mWT in individuals with acute neurologic
conditions. Clinically important change should also be de-
termined in chronic stable conditions. Studies to determine
the presence of floor and ceiling effects should be conduct-
ed in persons with chronic progressive and chronic stable
conditions.
R. Research Recommendation 8: Studies are needed to
examine the Walk-12 in individuals with acute, chronic
progressive, and chronic stable neurologic conditions. Psy-
chometric properties such as reliability, internal consis-
tency, measurement error, floor and ceiling effects, MDCs,
and MIC/MCIDs should be established across neurologic
conditions.
R. Research Recommendation 9: Studies are needed to de-
termine the intrarater and interrater reliability, and clinically
important change (eg, MCID), of the 6MWT in individuals
with acute neurologic conditions. Data to assist in measuring
change (eg, MDC, SEM, and MCID) are needed in individu-
als with acute and chronic stable neurologic conditions.
R. Research Recommendation 10: Studies are needed that
explore the feasibility and psychometric properties of the
5TSTS to objectively describe the transfer abilities of adults
with neurologic conditions, especially those other than indi-
viduals with PD, across the continuum of care and spectrum
of acuity. Further study of the 30SCST is warranted, particu-
larly relative to reliability and data to interpret changes in
individuals with neurologic conditions.
R. Research Recommendation 11: Studies should explore
the feasibility and psychometric properties, including reli-
ability and data to assist in interpreting change (eg, MDC
and MCID/MIC) of the GAS and other OMs that capture the
individual goals of adults with neurologic conditions across
the continuum of care and spectrum of acuity.
R. Research Recommendation 12: Studies are needed that
explore the impact of using the core set of OMs on rehabili-
tation outcomes, including factors related to implementation
(eg, time and cost). Studies should explore the impact of us-
ing the core set of OMs to support clinical decision-making
across neurologic conditions and categories. Future measure-
ment studies should be designed to meet the COSMIN re-
quirements for excellent methodology with regard to sample
size, design, and rigor of statistical analysis of psychometric
properties.8,9,40,42
09/06/18 2:22 PM

R. Research Recommendation 13: The CPG KT Committee
is developing standardized administration procedures for all 6
OMs in the core set. Studies are needed to determine the psy-
chometric properties of these protocols across acute, chronic
progressive, and chronic conditions in clinical practice.
R. Research Recommendation 14: Research is needed
on the impact of discussing OM results and shared
216 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 216
JNPT • Volume 42, July 2018
decision-making with patients receiving neurologic physi-
cal therapy, including the development and impact of OM-
related information (eg, OM-related decision aids) on the
understanding and involvement of a patient in his/her care
and on the achievement of patient goals. Furthermore, re-
search should develop and test the use of decision aids that
incorporate the core set.
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
ACKNOWLEDGMENTS
The GDG has substantially benefitted from the contributions
and support provided by many, including patients, clinicians,
researchers, and methodologists throughout the development
of this CPG, from ideation to publication.
We would like to thank Chi-Hung Chang, PhD, who pro-
vided the GDG with invaluable methodological support in
the development of the clinician and consumer surveys and
the COSMIN-M. We would like to formally acknowledge
the support of the APTA for grant funding that supported
this CPG and specifically thank Matthew Elrod, PT, DPT,
MEd, NCS, and Anita Bemis-Dougherty, PT, DPT, MAS.
We are grateful for the ongoing guidance and support
provided by the ANPT, specifically Beth Crowner, PT, DPT,
NCS, MPPA, Director of Practice, the Evidence-Based Doc-
uments Advisory Committee, and our liaison, Miriam Raf-
ferty, PT, DPT, PhD.
We thank the Clinical Neuroscience Research Registry
at the Rehabilitation Institute of Chicago and Northwestern
University, Heartland Chapter of the National Parkinson’s
Disease Foundation, and the Mid America Chapter of the
National Multiple Sclerosis Society for their support and as-
sistance with distributing our survey to consumers of physi-
cal therapy.
We are grateful to our expert panel members whose di-
verse perspectives and expertise helped guide our work. Our
expert panelists included: Mary Beveridge; Kristen Bode,
PT; Rhea Cohn, PT, DPT; Rebecca Craik, PT, PhD, FAPTA;
Anna De Joya, PT, DSc, NCS; Judith Deutsch, PT, PhD,
FAPTA; Jan Douglas, OTR/L; Edelle Field-Fote, PT, PhD,
FAPTA; Timothy Hanke, PT, PhD; Allen Heinemann, PhD;
Ann Jeppesen, PT, MPT; Jacob Kean, SLP, PhD; Catherine
Lang, PT, PhD; Deborah Larsen, PT, PhD; Nancy Mayo,
PT, BSc, MSc, PhD; Lorna Paul, PT, PhD; Jeff Rizner; Regi
Robnett, PhD, OTR/L; Mark Stephan; Keiko Thomas, OT,
PhD; David Tirschwell, MD, MSc; Mary Van de Kamp,
CCC-SLP; and Vanessa Warner, PT, DPT, NCS.
We are grateful to members of the ANPT who vol-
unteered to review the literature. The critical appraisal
team included: Kathryn Brown, PT; Melissa DiLorenzo,
PT, DPT; Lisa Dutton, PT, PhD; Laura Dylus, PT, MSPT,
NCS; Heather Hayes, DPT, PhD, NCS; Kaitlin Hays, PT,
DPT, NCS; Kristen M. Johnson, PT, EdD, MS, NCS; Sarah
Keller, PT, DPT, NCS; Thomas Longbottom, PT, DPT, NCS;
Jackie Madsen, PT, DPT, NCS, GCS; Kathryn D. Mitch-
ell, PT, DPT, NCS, MSCS; Holly Roberts, PT, DPT, GCS,
NCS; Jennifer Schwartz, PT, DPT, NCS; Elizabeth Scott,
PT, DPT, NCS, MSCS; Ted J. Stevenson, PT, MSc; Suzanne
Trojanowski, PT, DPT, NCS; Diana Veneri, PT, EdD, NCS,
RYT; Amanda Wu, PT, DPT, NCS; Katherine Winborn, PT,
DPT, MS, NCS; Elizabeth Yates Horton, PT, DPT, NCS; Rie
Yoshida, PT, DPT, NCS; and Hallie Zeleznik, PT, DPT, NCS.
We are very grateful for the ongoing work and the col-
laboration of the CPG KT Committee. This committee in-
cludes: Maggie Bland (Co-Chair), PT, DPT, NCS, MSCI;
Amelia Siles (Co-Chair), PT, DPT, NCS; Teresa Rice, PT,
MPH, NCS; Genevieve Olivier, PT, DPT, NCS; Hallie Zele-
nik, PT, DPT; Megan Eikenberry, PT, DPT, NCS; Arlene
McCarthy, PT, MS, DPT, NCS; Wendy Romney, PT, DPT,
NCS; and Elizabeth “Libby” Anderl, PT, DPT.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 217
JNPT-D-17-00190.indd 217
REFERENCES
1. Mokkink LB, Terwee CB, Knol DL, et al. Protocol of the COS-
MIN study: COnsensus-based Standards for the selection of health
Measurement INstruments. BMC Med Res Methodol. 2006;6:2.
2. Mokkink LB, Terwee CB, Gibbons E, et al. Inter-rater agreement
and reliability of the COSMIN (COnsensus-based Standards for
the selection of health status Measurement Instruments) checklist.
BMC Med Res Methodol. 2010;10:82.
3. Mokkink LB, Terwee CB, Knol DL, et al. The COSMIN checklist
for evaluating the methodological quality of studies on measure-
ment properties: a clarification of its content. BMC Med Res Meth-
odol. 2010;10:22.
4. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN study
reached international consensus on taxonomy, terminology, and
definitions of measurement properties for health-related patient-
reported outcomes. J Clin Epidemiol. 2010;63(7):737-745.
5. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN check-
list for assessing the methodological quality of studies on mea-
surement properties of health status measurement instruments: an
international Delphi study. Qual Life Res. 2010;19(4):539-549.
6. Institute of Medicine. Clinical Practice Guidelines We Can Trust.
Washington, DC: The National Academies Press; 2011.
7. Fetters L, Tilson J. Evidence Based Physical Therapy. Philadelphia,
PA: FA Davis; 2012.
8. Terwee CB. Protocol for Systematic Reviews of Measurement
Properties. Amsterdam, the Netherlands: Knowledge Center Mea-
surement Instruments; 2011. http://www.cosmin.nl/images/up-
load/files/Protocol%20klinimetrische%20review%20version%20
nov%202011.pdf
9. Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were pro-
posed for measurement properties of health status questionnaires.
J Clin Epidemiol. 2007;60(1):34-42.
10. Steffen T, Seney M. Test-retest reliability and minimal detectable
change on balance and ambulation tests, the 36-item short-form
health survey, and the unified Parkinson disease rating scale in
people with parkinsonism. Phys Ther. 2008;88(6):733-746.
11. Quinn L, Khalil H, Dawes H, et al. Reliability and minimal de-
tectable change of physical performance measures in individuals
with pre-manifest and manifest Huntington disease. Phys Ther.
2013;93(7):942-956.
12. American Physical Therapy Association. Clinical Practice Guide-
lines. http://www.apta.org/EvidenceResearch/EBPTools/CPGs/.
Accessed October 10, 2017.
13. American Physical Therapy Association. Guide to Physical Therapist
Practice 3.0. http://guidetoptpractice.apta.org/. Accessed June 24,
2017.
14. International Classification of Functioning, Disability, and health:
ICF [computer program]. Version 1.0. Geneva, Switzerland: World
Health Organization; 2001.
15. Potter K, Fulk GD, Salem Y, Sullivan J. Outcome measures in
neurological physical therapy practice: part I. Making sound deci-
sions. J Neurol Phys Ther. 2011;35(2):57-64.
16. Sullivan JE, Andrews AW, Lanzino D, Perron AE, Potter KA. Out-
come measures in neurological physical therapy practice: part II.
A patient-centered process. J Neurol Phys Ther. 2011;35(2):65-74.
17. Potter K, Cohen ET, Allen DD, et al. Outcome measures for indi-
viduals with multiple sclerosis: recommendations from the Ameri-
can Physical Therapy Association Neurology Section task force.
Phys Ther. 2014;94(5):593-608.
18. Sullivan JE, Crowner BE, Kluding PM, et al. Outcome measures
for individuals with stroke: process and recommendations from
the American Physical Therapy Association neurology section task
force. Phys Ther. 2013;93(10):1383-1396.
19. Kahn JH, Tappan R, Newman CP, et al. Outcome measure recom-
mendations from the spinal cord injury EDGE task force. Phys
Ther. 2016;96(11):1832-1842.
20. McCulloch KL, de Joya AL, Hays K, et al. Outcome measures
for persons with moderate to severe traumatic brain injury: rec-
ommendations from the American Physical Therapy Association
09/06/18 2:22 PM

Academy of Neurologic Physical Therapy TBI EDGE Task Force.
J Neurol Phys Ther. 2016;40(4):269-280.
21. Academy of Neurologic Physical Therapy. Academy of Neurologic
PT Outcome Measures Recommendations. http://www.neuropt.
org/professional-resources/neurology-section-outcome-measures-
recommendations. Accessed June 25, 2017.
22. Institute of Medicine. Best Care at Lower Cost: The Path to
Continuously Learning Health Care in America. Washington, DC:
Institute of Medicine; 2013.
23. Haigh R, Tennant A, Biering-Sorensen F. The use of outcome mea-
sures in physical medicine and rehabilitation in Europe. Eur J Re-
habil Med. 2001;33:273-278.
24. Jette DU, Halbert J, Iverson C, Miceli E, Shah P. Use of standard-
ized outcome measures in physical therapist practice: perceptions
and applications. Phys Ther. 2009;89(2):125-135.
25. Andrews AW, Folger SE, Norbet SE, Swift LC. Tests and measures
used by specialist physical therapists when examining patients
with stroke. J Neurol Phys Ther. 2008;32(3):122-128.
26. Thier SO. Forces motivating the use of health status assessment
measures in clinical settings and related clinical research. Med
Care. 1992;30(5 suppl):MS15-MS22.
27. Lansky D, Butler JB, Waller FT. Using health status measures in
the hospital setting: from acute care to “outcomes management.”
Med Care. 1992;30(5 suppl):MS57-MS73.
28. Cano SJ, Hobart JC. Watch out, watch out, the FDA are about. Dev
Med Child Neurol. 2008;50(6):408-409.
29. Fulk G, Field-Fote EC. Measures of evidence in evidence-based
practice. J Neurol Phys Ther. 2011;35(2):55-56.
30. Horn SD, Gassaway J, Pentz L, James R. Practice-based evi-
dence for clinical practice improvement: an alternative study de-
sign for evidence-based medicine. Stud Health Technol Inform.
2010;151:446-460.
31. Salter KL, Teasell RW, Foley NC, Jutai JW. Outcome assessment
in randomized controlled trials of stroke rehabilitation. Am J Phys
Med Rehabil. 2007;86(12):1007-1012.
32. Van Peppen RP, Maissan FJ, Van Genderen FR, Van Dolder R, Van
Meeteren NL. Outcome measures in physiotherapy management
of patients with stroke: a survey into self-reported use, and barriers
to and facilitators for use. Physiother Res Int. 2008;13(4):255-270.
33. Wedge FM, Braswell-Christy J, Brown CJ, Foley KT, Graham C,
Shaw S. Factors influencing the use of outcome measures in physi-
cal therapy practice. Physiother Theory Pract. 2012;28(2):119-
133.
34. Stevens JG, Beurskens AJ. Implementation of measurement in-
struments in physical therapist practice: development of a tailored
strategy. Phys Ther. 2010;90(6):953-961.
35. Abrams D, Davidson M, Harrick J, Harcourt P, Zylinski M, Clancy
J. Monitoring the change: current trends in outcome measure us-
age in physiotherapy. Man Ther. 2006;11(1):46-53.
36. Beattie P, Maher C. The role of functional status questionnaires for
low back pain. Aust J Physiother. 1997;43(1):29-38.
37. Centers for Medicare & Medicaid Services. Functional Reporting:
PT, OT, and SLP Services Frequently Asked Questions Document
Now Available. https://www.cms.gov/Medicare/Billing/Therapy-
Services/Functional-Reporting.html. Published 2014. Accessed
June 25, 2017.
38. American Physical Therapy Association. Functional Limitation
Reporting (FLR) Under Medicare: Tests and Measures for High-
Volume Conditions. http://www.ptnow.org/FunctionalLimitation-
Reporting/TestsMeasures/. Accessed June 25, 2017.
39. Moore JL, Raad J, Ehrlich-Jones L, Heinemann AW. Development
and use of a knowledge translation tool: the rehabilitation mea-
sures database. Arch Phys Med Rehabil. 2014;95(1):197-202.
40. Terwee CB, Jansma EP, Riphagen II, de Vet HC. Development of
a methodological PubMed search filter for finding studies on mea-
surement properties of measurement instruments. Qual Life Res.
2009;18(8):1115-1123.
41. COnsensus-based Standards for the selection of health Measure-
ment Instruments home page. http://www.cosmin.nl/. Accessed
June 25, 2017.
218 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 218
JNPT • Volume 42, July 2018
42. Terwee CB, Mokkink LB, Knol DL, Ostelo RW, Bouter LM, de
Vet HC. Rating the methodological quality in systematic reviews
of studies on measurement properties: a scoring system for the
COSMIN checklist. Qual Life Res. 2012;21(4):651-657.
43. SurveyMonkey home page. https://www.surveymonkey.com/. Ac-
cessed June 25, 2017.
44. Guideline Elements Model. BridgeWiz for APTA 3.0. http://gem.
med.yale.edu/BRIDGE-Wiz/. Published 2011. Accessed June 25,
2017.
45. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advanc-
ing guideline development, reporting and evaluation in health care.
CMAJ. 2010;182(18):E839-E842.
46. Shiffman RN, Dixon J, Brandt C, et al. The GuideLine Imple-
mentability Appraisal (GLIA): development of an instrument to
identify obstacles to guideline implementation. BMC Med Inform
Decis Mak. 2005;5:23.
47. Gustavsen M, Aamodt G, Mengshoel AM. Measuring balance in
sub-acute stroke rehabilitation. Adv Physiother. 2006;8(1):15-22.
48. Lemay JF, Nadeau S. Standing balance assessment in ASIA D
paraplegic and tetraplegic participants: concurrent validity of the
Berg Balance Scale. Spinal Cord. 2010;48(3):245-250.
49. Mao HF, Hsueh IP, Tang PF, Sheu CF, Hsieh CL. Analysis and
comparison of the psychometric properties of three balance mea-
sures for stroke patients. Stroke. 2002;33(4):1022-1027.
50. Knorr S, Brouwer B, Garland SJ. Validity of the Community Bal-
ance and Mobility Scale in community-dwelling persons after
stroke. Arch Phys Med Rehabil. 2010;91(6):890-896.
51. Tsang CS, Liao LR, Chung RC, Pang MY. Psychometric proper-
ties of the Mini-Balance Evaluation Systems Test (Mini-BESTest)
in community-dwelling individuals with chronic stroke. Phys
Ther. 2013;93(8):1102-1115.
52. Schlenstedt C, Brombacher S, Hartwigsen G, Weisser B, Moller
B, Deuschl G. Comparing the Fullerton Advanced Balance Scale
with the Mini-BESTest and Berg Balance Scale to assess postural
control in patients with Parkinson disease. Arch Phys Med Rehabil.
2015;96(2):218-225.
53. Donoghue D, Stokes EK. How much change is true change? The
minimum detectable change of the Berg Balance Scale in elderly
people. J Rehabil Med. 2009;41(5):343-346.
54. Downs S, Marquez J, Chiarelli P. The Berg Balance Scale has high
intra- and inter-rater reliability but absolute reliability varies across
the scale: a systematic review. J Physiother. 2013;59(2):93-99.
55. Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring
balance in the elderly: preliminary development of an instrument.
Physiother Can. 1989;41(6):304-311.
56. Blum L, Korner-Bitensky N. Usefulness of the Berg Balance
Scale in stroke rehabilitation: a systematic review. Phys Ther.
2008;88(5):559-566.
57. Pickenbrock HM, Diel A, Zapf A. A comparison between the Stat-
ic Balance Test and the Berg Balance Scale: validity, reliability,
and comparative resource use. Clin Rehabil. 2016;30(3):288-293.
58. Stevenson TJ. Detecting change in patients with stroke using the
Berg Balance Scale. Aust J Physiother. 2001;47(1):29-38.
59. Salter K, Jutai J, Foley N, Teasell R. Clinical Outcome Variables
Scale: a retrospective validation study in patients after stroke. J
Rehabil Med. 2010;42(7):609-613.
60. Chinsongkram B, Chaikeeree N, Saengsirisuwan V, Viriyatharakij
N, Horak FB, Boonsinsukh R. Reliability and validity of the Bal-
ance Evaluation Systems Test (BESTest) in people with subacute
stroke. Phys Ther. 2014;94(11):1632-1643.
61. Delbaere K, Close JC, Mikolaizak AS, Sachdev PS, Brodaty
H, Lord SR. The Falls Efficacy Scale International (FES-I).
A comprehensive longitudinal validation study. Age Ageing.
2010;39(2):210-216.
62. Leddy AL, Crowner BE, Earhart GM. Functional gait assessment
and balance evaluation system test: reliability, validity, sensitivity,
and specificity for identifying individuals with Parkinson disease
who fall. Phys Ther. 2011;91(1):102-113.
63. Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable changes
of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed
09/06/18 2:22 PM
 JNPT • Volume 42, July 2018 A Core Set of OMs for Adults With Neurologic Conditions Undergoing Rehabilitation
“Up & Go” Test, gait speeds, and 2-minute walk test in individuals
with chronic stroke with different degrees of ankle plantarflexor
tone. Arch Phys Med Rehabil. 2012;93(7):1201-1208.
64. Liaw LJ, Hsieh CL, Lo SK, Chen HM, Lee S, Lin JH. The relative
and absolute reliability of two balance performance measures in
chronic stroke patients. Disabil Rehabil. 2008;30(9):656-661.
65. Wirz M, Muller R, Bastiaenen C. Falls in persons with spinal cord
injury: validity and reliability of the Berg Balance Scale. Neurore-
habil Neural Repair. 2010;24(1):70-77.
66. Paltamaa J, Sarasoja T, Leskinen E, Wikstrom J, Malkia E. Mea-
suring deterioration in international classification of functioning
domains of people with multiple sclerosis who are ambulatory.
Phys Ther. 2008;88(2):176-190.
67. Verheyden G, Vereeck L, Truijen S, et al. Trunk performance after
stroke and the relationship with balance, gait and functional abil-
ity. Clin Rehabil. 2006;20(5):451-458.
68. Verheyden G, Nuyens G, Nieuwboer A, Van Asch P, Ketelaer P, De
Weerdt W. Reliability and validity of trunk assessment for people
with multiple sclerosis. Phys Ther. 2006;86(1):66-76.
69. Marchetti GF, Lin CC, Alghadir A, Whitney SL. Responsiveness
and minimal detectable change of the dynamic gait index and
functional gait index in persons with balance and vestibular disor-
ders. J Neurol Phys Ther. 2014;38(2):119-124.
70. Wrisley DM, Marchetti GF, Kuharsky DK, Whitney SL. Reli-
ability, internal consistency, and validity of data obtained with the
functional gait assessment. Phys Ther. 2004;84(10):906-918.
71. Lin JH, Hsu MJ, Hsu HW, Wu HC, Hsieh CL. Psychometric com-
parisons of 3 functional ambulation measures for patients with
stroke. Stroke. 2010;41(9):2021-2025.
72. Nilsagård Y, Kollén L, Axelsson H, Bjerlemo B, Forsberg A. Func-
tional Gait Assessment: reliability and validity in people with pe-
ripheral vestibular disorders. Int J Ther Rehabil. 2014;21(8):367-
373.
73. Marchetti GF, Whitney SL. Construction and validation of the
4-item dynamic gait index. Phys Ther. 2006;86(12):1651-1660.
74. Wrisley DM, Walker ML, Echternach JL, Strasnick B. Reliability
of the dynamic gait index in people with vestibular disorders. Arch
Phys Med Rehabil. 2003;84(10):1528-1533.
75. Huang SL, Hsieh CL, Wu RM, Tai CH, Lin CH, Lu WS. Mini-
mal detectable change of the timed “up & go” test and the dy-
namic gait index in people with Parkinson disease. Phys Ther.
2011;91(1):114-121.
76. Matsuda PN, Taylor CS, Shumway-Cook A. Evidence for the va-
lidity of the modified dynamic gait index across diagnostic groups.
Phys Ther. 2014;94(7):996-1004.
77. Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest,
BESTest, and BESTest sections for balance assessments in
individuals with Parkinson disease. J Neurol Phys Ther. 2011;35(2):
90-97.
78. Nilsagård Y, Lundholm C, Gunnarsson LG, Dcnison E. Clini-
cal relevance using timed walk tests and “timed up and go”
testing in persons with multiple sclerosis. Physiother Res Int.
2007;12(2):105-114.
79. Paul SS, Canning CG, Sherrington C, Fung VS. Reproducibility
of measures of leg muscle power, leg muscle strength, postural
sway and mobility in people with Parkinson’s disease. Gait Pos-
ture. 2012;36(3):639-642.
80. Stolwijk-Swuste JM, Beelen A, Lankhorst GJ, Nollet F; CARPA
Study Group. SF36 physical functioning scale and 2-minute walk
test advocated as core qualifiers to evaluate physical functioning in
patients with late-onset sequelae of poliomyelitis. J Rehabil Med.
2008;40(5):387-394.
81. Ng SS, Hui-Chan CW. The timed up & go test: its reliability
and association with lower-limb impairments and locomotor ca-
pacities in people with chronic stroke. Arch Phys Med Rehabil.
2005;86(8):1641-1647.
82. Powell LE, Myers AM. The Activities-specific Balance Confidence
(ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50A(1):M28-
M34.
©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA 219
JNPT-D-17-00190.indd 219
83. Jonasson SB, Nilsson MH, Lexell J. Psychometric properties of
four fear of falling rating scales in people with Parkinson’s disease.
BMC Geriatr. 2014;14:66.
84. Salbach NM, Mayo NE, Hanley JA, Richards CL, Wood-
Dauphinee S. Psychometric evaluation of the original and Canadian
French version of the activities-specific balance confidence scale
among people with stroke. Arch Phys Med Rehabil. 2006;87(12):
1597-1604.
85. Morgan MT, Friscia LA, Whitney SL, Furman JM, Sparto PJ. Reli-
ability and validity of the Falls Efficacy Scale-International (FES-
I) in individuals with dizziness and imbalance. Otol Neurotol.
2013;34(6):1104-1108.
86. van Vliet R, Hoang P, Lord S, Gandevia S, Delbaere K. Falls ef-
ficacy scale-international: a cross-sectional validation in people
with multiple sclerosis. Arch Phys Med Rehabil. 2013;94(5):883-
889.
87. Scrivener K, Schurr K, Sherrington C. Responsiveness of the ten-
metre walk test, Step Test and Motor Assessment Scale in inpatient
care after stroke. BMC Neurol. 2014;14:129.
88. Perera S, Mody SH, Woodman RC, Studenski SA. Meaning-
ful change and responsiveness in common physical performance
measures in older adults. J Am Geriatr Soc. 2006;54(5):743-749.
89. Scivoletto G, Tamburella F, Laurenza L, Foti C, Ditunno JF,
Molinari M. Validity and reliability of the 10-m walk test and
the 6-min walk test in spinal cord injury patients. Spinal Cord.
2011;49(6):736-740.
90. Rossier P, Wade DT. Validity and reliability comparison of 4 mo-
bility measures in patients presenting with neurologic impairment.
Arch Phys Med Rehabil. 2001;82(1):9-13.
91. Franchignoni F, Tesio L, Benevolo E, Ottonello M. Psychometric
properties of the Rivermead Mobility Index in Italian stroke reha-
bilitation inpatients. Clin Rehabil. 2003;17(3):273-282.
92. Hsueh IP, Wang CH, Sheu CF, Hsieh CL. Comparison of psy-
chometric properties of three mobility measures for patients with
stroke. Stroke. 2003;34(7):1741-1745.
93. Chen HM, Hsieh CL, Sing Kai L, Liaw LJ, Chen SM, Lin JH. The
test-retest reliability of 2 mobility performance tests in patients
with chronic stroke. Neurorehabil Neural Repair. 2007;21(4):347-
352.
94. Freeman J, Walters R, Ingram W, Slade A, Hobart J, Zajicek J.
Evaluating change in mobility in people with multiple sclerosis:
relative responsiveness of four clinical measures. Mult Scler.
2013;19(12):1632-1639.
95. Solari A, Radice D, Manneschi L, Motti L, Montanari E. The mul-
tiple sclerosis functional composite: different practice effects in
the three test components. J Neurol Sci. 2005;228(1):71-74.
96. Larson RD, Larson DJ, Baumgartner TB, White LJ. Repeatability
of the timed 25-foot walk test for individuals with multiple sclero-
sis. Clin Rehabil. 2013;27(8):719-723.
97. Learmonth YC, Dlugonski DD, Pilutti LA, Sandroff BM,
Motl RW. The reliability, precision and clinically meaningful
change of walking assessments in multiple sclerosis. Mult Scler.
2013;19(13):1784-1791.
98. Motl RW, Learmonth YC, Pilutti LA, Dlugonski D, Klaren R. Va-
lidity of minimal clinically important difference values for the mul-
tiple sclerosis walking scale-12? Eur Neurol. 2014;71(3/4):196-
202.
99. Nieuwenhuis MM, Van Tongeren H, Sorensen PS, Ravnborg M.
The six spot step test: a new measurement for walking ability in
multiple sclerosis. Mult Scler. 2006;12(4):495-500.
100. Phan-Ba R, Pace A, Calay P, et al. Comparison of the timed 25-foot
and the 100-meter walk as performance measures in multiple scle-
rosis. Neurorehabil Neural Repair. 2011;25(7):672-679.
101. Stellmann JP, Vettorazzi E, Poettgen J, Heesen C. A 3meter
Timed Tandem Walk is an early marker of motor and cerebel-
lar impairment in fully ambulatory MS patients. J Neurol Sci.
2014;346(1/2):99-106.
102. Baert I, Freeman J, Smedal T, et al. Responsiveness and clini-
cally meaningful improvement, according to disability level,
09/06/18 2:22 PM

of five walking measures after rehabilitation in multiple sclero-
sis: a European multicenter study. Neurorehabil Neural Repair.
2014;28(7):621-631.
103. Holland A, O’Connor RJ, Thompson AJ, Playford ED, Hobart JC.
Talking the talk on walking the walk: a 12-item generic walking
scale suitable for neurological conditions? J Neurol. 2006;253(12):
1594-1602.
104. Liu J, Drutz C, Kumar R, et al. Use of the six-minute walk test
poststroke: is there a practice effect? Arch Phys Med Rehabil.
2008;89(9):1686-1692.
105. ATS Committee on Proficiency Standards for Clinical Pulmo-
nary Function Laboratories. ATS statement: guidelines for the
six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):
111-117.
106. Salbach NM, O’Brien KK, Brooks D, et al. Considerations for the
selection of time-limited walk tests poststroke: a systematic review
of test protocols and measurement properties. J Neurol Phys Ther.
2017;41(1):3-17.
107. Lennon S, Johnson L. The modified Rivermead mobility index:
validity and reliability. Disabil Rehabil. 2000;22(18):833-839.
108. Walsh JM, Barrett A, Murray D, Ryan J, Moroney J, Shannon M.
The Modified Rivermead Mobility Index: reliability and conver-
gent validity in a mixed neurological population. Disabil Rehabil.
2010;32(14):1133-1139.
109. Radman L, Forsberg A, Nilsagard Y. Modified Rivermead Mobil-
ity Index: a reliable measure in people within 14 days post-stroke.
Physiother Theory Pract. 2015;31(2):126-129.
110. Duncan PW, Lai SM, Tyler D, Perera S, Reker DM, Studenski S.
Evaluation of proxy responses to the Stroke Impact Scale. Stroke.
2002;33(11):2593-2599.
111. Hilari K, Owen S, Farrelly SJ. Proxy and self-report agreement on
the Stroke and Aphasia Quality of Life Scale-39. J Neurol Neuro-
surg Psychiatry. 2007;78(10):1072-1075.
112. Oczkowski C, O’Donnell M. Reliability of proxy respondents for
patients with stroke: a systematic review. J Stroke Cerebrovasc
Dis. 2010;19(5):410-416.
113. Elder NC, Imhoff R, Chubinski J, et al. Congruence of patient self-
rating of health with family physician ratings. J Am Board Fam
Med. 2017;30(2):196-204.
114. Ruble L, McGrew JH, Toland MD. Goal attainment scaling as an
outcome measure in randomized controlled trials of psychosocial
interventions in autism. J Autism Dev Disord. 2012;42(9):1974-
1983.
115. Stolee P, Rockwood K, Fox RA, Streiner DL. The use of goal
attainment scaling in a geriatric care setting. J Am Geriatr Soc.
1992;40(6):574-578.
116. Turner-Stokes L, Williams H, Johnson J. Goal attainment scaling:
does it provide added value as a person-centred measure for evalu-
ation of outcome in neurorehabilitation following acquired brain
injury? J Rehabil Med. 2009;41(7):528-535.
117. Khan F, Pallant JF, Turner-Stokes L. Use of goal attainment scaling
in inpatient rehabilitation for persons with multiple sclerosis. Arch
Phys Med Rehabil. 2008;89(4):652-659.
118. Cusick A, McIntyre S, Novak I, Lannin N, Lowe K. A comparison
of goal attainment scaling and the Canadian Occupational Perfor-
mance Measure for paediatric rehabilitation research. Pediatr Re-
habil. 2006;9(2):149-157.
119. Hurn J, Kneebone I, Cropley M. Goal setting as an outcome mea-
sure: a systematic review. Clin Rehabil. 2006;20(9):756-772.
120. Harlos K, Tetroe J, Graham ID, Bird M, Robinson N. Mining the
management literature for insights into implementing evidence-
based change in healthcare. Healthc Policy. 2012;8(1):33-48.
121. Field-Fote E. Towards Optimal Practice. What can we gain from
assessment of patient progress with standardized outcome mea-
sures? http://www.ptresearch.org/article/104/resources/research-
ers/edge-task-force-evaluation-database-to-guide-effectiveness.
Accessed July 26, 2017.
122. Paul L, Coote S, Crosbie J, et al. Core outcome measures for exercise
studies in people with multiple sclerosis: recommendations from
220 ©2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Academy of Neurologic Physical Therapy, APTA
JNPT-D-17-00190.indd 220
JNPT • Volume 42, July 2018
a multidisciplinary consensus meeting. Mult Scler. 2014;20(12):
1641-1650.
123. Verschuren O, Ketelaar M, Keefer D, et al. Identification of a core
set of exercise tests for children and adolescents with cerebral pal-
sy: a Delphi survey of researchers and clinicians. Dev Med Child
Neurol. 2011;53(5):449-456.
124. Grill E, Bronstein A, Furman J, Zee DS, Muller M. International
Classification of Functioning, Disability and Health (ICF) Core
Set for patients with vertigo, dizziness and balance disorders. J
Vestib Res. 2012;22(5/6):261-271.
125. Winser SJ, Smith C, Hale LA, Claydon LS, Whitney SL. Balance
outcome measures in cerebellar ataxia: a Delphi survey. Disabil
Rehabil. 2015;37(2):165-170.
126. Sibley KM, Howe T, Lamb SE, et al. Recommendations for a core
outcome set for measuring standing balance in adult populations:
a consensus-based approach. PLoS One. 2015;10(3):e0120568.
127. Herrmann KH, Kirchberger I, Stucki G, Cieza A. The comprehen-
sive ICF core sets for spinal cord injury from the perspective of
physical therapists: a worldwide validation study using the Delphi
technique. Spinal Cord. 2011;49(4):502-514.
128. Lennon S. Physiotherapy practice in stroke rehabilitation: a sur-
vey. Disabil Rehabil. 2003;25(9):455-461.
129. Stacey D, Legare F, Lewis K, et al. Decision aids for people facing
health treatment or screening decisions. Cochrane Database Syst
Rev. 2017;4:CD001431.
130. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a mod-
el for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367.
131. Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson
R. Implementing shared decision making in the NHS. BMJ.
2010;341:c5146.
132. Government of Canada. Canadian Institutes of Health Research
Act. http://laws.justice.gc.ca/eng/acts/c-18.1/page-1.html. Ac-
cessed July 27, 2017.
133. Nilsen P. Making sense of implementation theories, models and
frameworks. Implement Sci. 2015;10:53.
134. Hudon A, Gervais MJ, Hunt M. The contribution of conceptual
frameworks to knowledge translation interventions in physical
therapy. Phys Ther. 2015;95(4):630-639.
135. Levac D, Glegg SMN, Camden C, Rivard LM, Missiuna C. Best
practice recommendations for the development, implementation,
and evaluation of online knowledge translation resources in reha-
bilitation. Phys Ther. 2015;95(4):648-662.
136. Zidarov D, Thomas A, Poissant L. Knowledge translation in
physical therapy: from theory to practice. Disabil Rehabil.
2013;35(18):1571-1577.
137. Field B, Booth A, Ilott I, Gerrish K. Using the Knowledge to Ac-
tion Framework in practice: a citation analysis and systematic re-
view. Implement Sci. 2014;9:172.
138. Moulding NT, Silagy CA, Weller DP. A framework for effective
management of change in clinical practice: dissemination and
implementation of clinical practice guidelines. Qual Health Care.
1999;8(3):177-183.
139. Straus SE, Tetroe J, Graham ID. Knowledge Translation in Health
Care. West Sussex, UK: John Wiley & Sons; 2013.
140. Andresen EM. Criteria for assessing the tools of disability out-
comes research. Arch Phys Med Rehabil. 2000;81(12, suppl
2):S15-S20.
141. Post MW. What to do with “moderate” reliability and validity coef-
ficients? Arch Phys Med Rehabil. 2016;97(7):1051-1052.
142. Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluating patient-
based outcome measures for use in clinical trials. Health Technol
Assess. 1998;2(14):i-iv, 1-74.
143. Colquhoun HL, Lamontagne ME, Duncan EA, Fiander M,
Champagne C, Grimshaw JM. A systematic review of interven-
tions to increase the use of standardized outcome measures by re-
habilitation professionals. Clin Rehabil. 2017;31(3):299-309.
144. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects
on professional practice and healthcare outcomes. Cochrane Data-
base Syst Rev. 2012;(6):CD000259.
09/06/18 2:22 PM